UNIVERSITY OF CALIFORNIA
AT LOS ANGELES
GIFT OF
BIOLOGY DEPART!;!!
\
NOTES
HOSPITAL PRACTICE
PART I.
PHILADELPHIA HOSPITALS.
SELECTED AND ARRANGED BY
SAMUEL M. MILLER M. D.
PHILADELPHIA, PA.
SAMUEL M. MII.LER, M. D., Publisher.
COPYRIGHTED, iSSi
v, i-z
PREFACE.
The following diagnostic and therapeutical notes have,
many of them, been condensed and collated by me from
my reports of clinical lectures and notes of hospital
practice, which have appeared originally in the New York
Medical Record, New York Hospital Gazette, Boston Medi-
cal and Surgical Journal, Philadelphia Medical Times,
Philadelphia Medical and Surgical Reporter, Cincinnati
Clinic and Scientific American; while others are now
i*- published for the first time. Every effort has been
t made to secure accuracy, and it is hoped that the "Notes"
5
will prove of service to the busy practitioner, for whom
they are mainlv intended. THE PUBLISHEKt
248911
GENERAL DISEASES.
SOME INTERESTING POINTS IN THE DIAGNOSIS AND PROGNO-
SIS OF TYPHOID FEVER.
The case was that of a sailor, admitted to the hospital on
the 27th of January, who had been in good health until four
days before his admission, when he complained of chilliness,
of fever, and of nausea, but of no headache. His nose bled
profusely, and his bowels became very loose. Upon his ad-
mission his face was singularly flushed, and he had a severe
pain in his back. His temperature was 104^ F., his pulse
92, and his respirations 24 to the minute. Nothing could be
detected in the condition of the lungs to account for the heavy
flush on his face. Upon examining the urine it was found to
contain granular hyaline casts and bladder epithelium. It
was re-examined, with the same result.
The man remained in the same condition, with morning
remissions and evening exacerbations, and with a few bronchial
rales in his lungs, until the afternoon of the day after his ad-
mission, when profuse epistaxis supervened, and the character-
istic rose-colored spots appeared on his abdomen, which grew
swollen and tympanitic. Stitt there was no headache. On the
evening of January 31st the man's temperature was 103 F.
Between January 27th and February 1st there was never a
difference of more than one degree between morning and evening
temperatures. On the morning of February 1st the pulse was
only 84, and the respirations 20 to the minute. The tongue
was of the characteristic appearance dry, cracked, reddish at
spots, devoid of coating, varnished-looking. The typical spots
on the chest and abdomen were slightly raised, and disappeared
upon pressure. There was some gurgling in the right iliac
fossa, and a moderate amount of abdominal distention. The
4 Notes of Hospital Practice.
bowels, after admission, were easily controlled by a single
opium suppository daily.
On February 1st the face was still flushed. The breathing
was rather harsh, and there were a few dry rales in the lungs.
Still no headache, and intellect clear.
Dr. DaCosta, in his examination of the case on February
1st, and remarks upon it, developed some points of much
novelty and interest.
The first sound of the heart he found to be very feeble, and
there was most marked throbbing of the vessels at the root
of the neck. He considered the case to be different from the
great majority of cases.
He wished to lay great stress upon the presence of albumen
in the urine upon the eighth day of the disease. The case
would have to be very closely watched. The presence of the
albumen might be explained in either one of two ways (1)
there might have been pre-existing disease of the kidneys as
a complication of the fever, or (2) the typhoid fever had pro-
duced the disease of the kidneys. If the latter alternative
were the true one and it so seemed to him the case was a
veiy grave one, for the albumen was noticed as early as the
fifth day of the disease. Early albuminuria, as a symptom,
never occurs in the course of typhoid fever unless the case is to
be a very grave one. Albumen is quite commonly found in
the urine of typhoid fever patients in the third week of the
disease. The slight difference between morning and evening
temperatures so early in the attack was anotJier bad sign.
Furthermore, the first sound of the heart was thus early
altered. Alteration in the first sound of the heart does not
usually occur until late in the course of the disease. When
Hie heart is affected early, it becomes a warning.
In closing, Dr. DaCosta wished to call attention to the
existence of flushed face, without any disease of the lungs. It
always was enough to raise suspicions as to the nature of the
disease, especially when accompanied by great throbbing of the
vessels at tfie root of the neck. This fact had struck him many
General Diseases. 5
years ago, and, upon entering a sick room and finding these
coincident symptoms, he used to make a rough diagnosis of
typhoid fever at once, without any further examination.
All these symptoms being as they were, it was determined
to shape the treatment accordingly. Up to February 1st, the
man had been taking f iij of whiskey daily. This quantity
was at once increased to f | v. Together with this, gtt. x of
muriatic acid was given every four hours. The daily dis-
tributed dose of quinia was gr. x. The man's diet wus very
carefully regulated, consisting principally of beef-tea and
milk. Diarrhoea was checked by opium suppositories. The
patient was sponged morning and evening with tepid water.
Fe6. 20A. The man is now convalescent, having been
carried through the attack by careful treatment. The albu-
minuria has disappeared.
SOME INTERESTING CASES OF TYPHOID FEVER, AND THEIR
TREATMENT.
The following cases occurred among the sailors of the Rus-
sian steamers which were built and repaired during the sum-
mer and fall of 1878, on the Delaware river at Philadelphia:
Out of 550 sailors, 30 were attacked with different grades
of typhoid fever. During the months of September, October,
November and December, these cases were brought to the
German Hospital. They were all seen by the attending phy-
sicians, Drs. Turnbull, Woodbury and Cohen.
With the assistance of Dr. Hermann and of the Russian
physicians, it was determined to ascertain the cause of the
outbreak. The majority of sick sailors came from one steamer,
and as their drinking water was different from that of the
officers, the first chie as to the cause of the disease was thus
found. Examining into this, right in the immediate vicinity
of this steamer a privy was found, a large part of the excre-
ment frDm which found its way into the water from which
the sailors drank. On the other steamers this state of things
o Notes of Hospital Practice.
was not found to exist, but the excrement and dirt on board
was thrown over into the river, from which they at first ob-
tained their drinking water. Surmising this to be the cause
of a few cases of the disease they resorted to another source
for their water, which caused the disappearance of the disease.
The interesting cases brought into the hospital were :
B., set. 23, robust constitution, entered the hospital after
feeling out of sorts for five days. From his own statement,
the prominent symptoms were, intense headache and great heat
in the evening ; did not seem to know the condition of his
bowels, nor could any other symptom be obtained from him.
On entering the hospital he presented the following condition :
Great headache, high fever, temperature 103 A. M., 104 P.
M., pulse 90 to 100, skin hot and dry, great thirst, bowels
constipated, tongue heavily coated with a dark-brown fur
deeply fissured, tenderness in right iliac fossa, no tympanitis
and no eruption. He remained in this condition for seven
days ; on the eighth day he became delirious, necessitating his
being tied with shackles ; he refused to take any nourishment
and would not respond to any command. His temperature
rose to 105 and his bowels were moved with an enema.
On the twelfth day his delirium became active, wild, and after
a heroic dose of morphia hypodermically, he appeared rational
the next morning ; his bowels were moved every third day
with an injection ; never once having the slightest tendency
to diarrhoea ; the injections acted very rapidly. On the four-
teenth day after admission his temperature fell to 104 P. M.,
103 A. M. ; less headache, the skin still hot and dry ; tongue
heavily coated with a dark fur deeply fissured; no rose-
colored spots could be found on the body, and his bowels were
still constipated. Late in the evening signs of approaching
delirium seemed evident and he was given a large hypodermic
injection of morphia; he slept well after the injection of
morphia and appeared rational the next morning.
He continued in this condition until the twenty-first day,
when his temperature rose to 105, with great tympanitis, and
General Diseases. 7
diffused abdominal tenderness. He lost consciousness and died
the same evening.
Autopsy. Body was much emaciated. Lungs consolidated
posteriorly, (hypostatic pneumonia.) Spleen enlarged and
softened. Peyer's patches were in different stages of inflam-
mation, some swollen, others sloughing and others having
nothing but peritoneum for the floor of the ulcer. No per-
foration was found. This was what would be called one of
the grave forms of typhoid fever, though the temperature did
not reach above 105. He was systematically fed, but the
emaciation in the last few days was very great.
The following is a good illustration of what has been called
an insidious, latent, or ambulatory form :
G., set. 37, was working at his usual duties as a sailor,
noticing nothing abnormal except a slight diarrhoea, which
caused so little disturbance as to pass unheeded. As he him-
self expressed it, his bowels were opened only once more than -
usual during the day. He had no evening heat, no lassitude,
nothing, in fact, that would lead one to think he had typhoid ;
fever. All of a sudden he felt a sharp pain in the abdomen, .
which, in a few hours grew unbearable; his belly became
very tympanitic and tender to the touch ; his temperature was
103, P. M. ; rose-colored spots were found on the abdomen.
He now presented all the symptoms of acute peritonitis and was
treated with opium. He died in twelve hours after his ad-
mission.
Autopsy revealed ulceration of Peyer's patches in the third
week, with a large perforation in an ulcer near the ileo-eoecal
valve; recent lymph over peritoneum and bowels, indicative
of peritonitis. Spleen enlarged and softened ; other organ*
found healthy.
In addition to these, there were some very mild cases, which
would be classed under the head of abortive variety. Three
cases of this kind presented themselves, .with the following
symptoms and course :
Some lassitude ; headache, which increased in intensity in
8 Notes of HospUul Practice.
the evening; temperature 102, p. M., 100, A. M, ; pulse, 90
to 100. Very little diarrhoea, stools thin in consistency and of
a yellow color. Tenderness over right iliac fossa. In ten
days three of these cases showed characteristic rose-colored spots
on abdomen, one having numerous spots on both extremities;
one, also, had considerable enlargement of the spleen.
In the beginning of the third week the temperature reached
the normal and all symptoms of fever declined. Bowels be-
came regular, headache disappeared, tongue clean, &c., &c.
These cases were kept under observation for weeks after-
wards to see if any untoward symptoms appeared, while at
the same time they were kept upon a liquid diet. Four
weeks afterwards they all left the hospital fat ; one stouter
than he was previous to the fever.
The following was a very grave case : E,., set. 22, entered
the hospital about the eighth day of the disease, with very
high fever, pulse rapid, 120 to 124, temperature 106, P. M.,
104, A. M., appetite capricious, tongue heavily coated and
very dry. Bowels very loose, having as many as twelve
stools per day, resembling pea-soup in appearance; his head-
ache was intense ; ringing in the ears and flashes of light
before the eyes. This condition of things went on for four
days, and then the characteristic eruption appeared. In the
meantime his diarrhoea had been checked by the treatment.
The temperature remained the same, and his headache was
increasing. On the thirteenth day, i. e., from the beginning
of the disease, he was suddenly seized with an active, wild
delirium, which required constant restraint and watching, in
order to prevent him from hurting himself.
He passed his urine and fteces in bed, unconscious of what
he was doing. His urine was examined and found highly
colored, acid on reaction, but no albumen. Two days after
the setting in of the delirium he became comatose, and died
shortly afterwards. The temperature the last two days was
105.
Autopsy showed the characteristic lesion of Peyer's patches,
with congestion of brain and lunos.
General Diseases. 9
The following seemed to be a recurrent attack of typhoid
fever showing an abortive course : C., set. 25, had all the
characteristic symptoms of the fever diarrhoea, headache,
tenderness in right iliac fossa, rose-colored spots and high
temperature. In the latter part of the fourth week the tem-
perature began to decline, and in five days reached the normal.
It remained normal for ten days, and he presented the condi-
tion of one convalescent from typhoid fever. Then the tem-
perature began to go up for five days, until it reached 103,
p. M., and remained stationery for six days, with a slight
morning remission. First, the diarrhoea and headache re-
turned, and two days afterwards the eruption re-appeared.
After thirteen days of relapse the temperature went down,
and in three days reached the normal. He was very soon
convalescent.
Out of thirty cases, twenty-one had diarrhoea differing in
severity ; some having nine to twelve stools, others two to five,
per diem ; four, constipation, (going five days without a pas-
sage from their bowels,) which was quickly relieved by an
enema. In the remaining six, diarrhoea and constipation oc-
curred alternately. Sometimes their bowels would be regular
for four or five days, and then diarrhoea or constipation would
set in, and so on throughout the course of the disease.
The eruption appeared in twenty-one cases the majority
showing it on the abdomen. It appeared, in a few cases, at
the same time, on the back. Two out of the thirty showed
spots on both extremities. The" number of spots varied; in
some as many as twenty-five were counted in others only
from two to five could be seen. The two having spots on the
lower extremities had the largest number. Tenderness in the
right iliac fossa was found in a good number of cases, but it
was also absent where undoubted signs of typhoid fever ex-
isted. Delirium showed itself in one-third of the whole
number of cases. Some had very high temperatures, and
others had very mild temperatures. Those cases having very
high temperatures, with active deliriuir, generally proved
fatal
10 Notes of Hospital Practice.
Three cases had a temperature of 106, but had no delirium
during the whole fever.
Lung complications occurred in the majority of the cases, in the
form of slight attacks of bronchitis, or of pneumonia, or pleu-
risy the former predominating. Hemorrhage from the
bowels occurred in one case, which recovered. As regards
the prognosis, the most unfavorable signs were high tempera-
ture, active and wild delirium, and severe diarrhoea. In two
of the fatal cases there was a very prominent symptom i. e.,
a quivering of the extremities upon the slightest motion.
When asked to put out the tongue, it came slowly, tremulous
and uncertain. These two patients were not able to protrude
the tongue to its fullest extent, or when they did so it was,
quickly retracted, on account of an inability to keep it out.
Such manifestations were of unfavorable omen.
THE TREATMENT OF TYPHOID FEVER.
Dr. Pepper regards the specific follicular catarrh of the in-
testines as of great importance in the determination of the
treatment. He holds that there are a number of remedies
which exert a powerful influence upon this catarrh. The first
of these is the nitrate of silver, which reduces the size of the
enlarged follicles, relieves the inflammatory engorgement, and
allays the hypersesthesia of the nerves. So too do carbolic
acid and the subnitrate of bismuth. He prefers the nitrate of
silver, and only substitutes carbolic acid in its place when
some putrid element is present. The nitrate of silver is given
in quarter-grain doses, four times daily. Opium in pill
form is combined with the silver when the diarrhoea is exces-
sive. From one- quarter of a grain all the way up to one grain
of opium is given thrice or four times daily. If the bowels are
constipated, l>elladonna is substituted in the place of opium.
Milk is regarded as the best diet during the stage of
catarrhal inflammation. The milk is diluted with lime-water
if the curd appears in the stools. Two pints of milk and
General Diseases. 11
lime-water, mixed, are given in the course of the twenty-four
hours.
The poisoned state of the blood is controlled by means of
quinia and salicylic acid. The latter has been found to be
very valuable in this condition as a disinfectant. Quinia is
given to the amount of not more than twelve grains in twenty-
four hours.
Temperature is kept down by preventive measures rather
than by the cold bath, which is regarded as a dernier ressoit.
When temperature runs up in spite of drugs, the whole body is
sponged every two hours the sponges being squeezed out of
a mixture of water and bay rum, at a temperature of from
60 to 80. If the patient's temperature still runs up he is
wrapped in sheets wrung out of cold water. The only case
in which the cold bath is used is in the first ten days, where
the temperature rises above 103, and is not to be controlled
by milder measures.
Stimulants are not administered to patients under the age
of puberty, as a general thing. They are only thought to be
demanded by some one or more of the following indications,
viz. : (1.) Ataxic nervous disturbances. (2.) Profound as-
thenia. (3.) Circulatory disturbances. (4.) Dry and brown
tongue with sordes. The milder forms of stimulus, such as
wine whey, are always used at first. When demanded, whis-
key is given with lime-water the latter being added to pre-
vent coagulation in the proportion of f 1 ss. each of whie-
key and lime-water to every f | iij. of milk.
Relapses are treated as first attacks. Hemorrhage is man-
aged by absolute rest in bed for twenty-four hours, and by
the administration of opium to produce absolute rest for thtj
alimentary canal. Acetate of lead is sometimes combined
with the opium in the shape of suppositories. Ergot is also
very useful. The food allowed is small in quantity and liquid,
Dr. Cohen finds that large doses of quinia rather increase
the diarrhoea and headache. His patients are sponged with
vinegar and water, and abundant ice is given them to suck.
12 Notes of Hospital Practice.
Oil of turpentine in 20 gtt. doses every hour or two in mucil-
age, he has found to act most beneficially. Morphia is given
hypodermically iu half-grain doses where the delirium ia
ictive.
Dr. William H. Bennett reduces the temperature and
strengthens the heart by 10 gtt. doses of digitalis thrice daily.
Dr. Louis Starr controls diarrhoea by starch and laudenum
enemata.
PLEURO-PNEUMONIA FOLLOWING TYPHOID FEVER DEATH
FROM LARGE PLEURITIC EFFUSION AT END OF SEVENTH
WEEK, WITH PEYER'S PATCHES STILL UNHEALED.
George Ross, set. 26, born in Massachusetts, a sailor, single ;
admitted October 30th, 1877 ; always enjoyed good health^
and denies venereal disease ; had been sick four weeks at sea
before admission, the principal symptoms being prostration
and some fever. He was in a condition of slight hebetude
when admitted. It was difficult to obtain much history, but
the captain of his ship stated that there had been no diarrhoea,
epistaxis, or actual delirium. Respiration was slightly jerk-
ing, but the lungs expanded well and no abnormal sounds
could be detected in the chest. He had no cough ; the abdo-
men was not tympanitic, and the marks of some kind of plas-
ter were noticed in the hypogastric and iliac regions.
Temperature upon admission was 101, the pulse 101, and
the respirations 24 to the minute. The patient was restless
and irritable and required watching at night, although there
was no marked delirium. He seemed rather dull and did not
complain of anything. Bowels were moved two or three
times daily after admission. The urine was light colored,
cloudy, sp. gr. 1010, no albumen and no sugar.
November 2d. Patient found to have left-sided pneumonia;
dullness at left base posteriorily, where there is also impaired
respiration, coarse crepitation, with bronchophony and bron-
chial breathing above and whiffling in respiration at line of
dullness. These signs were not found in the front, where the
General Diseases. 13
percussion note was clear on both sides, and the respiration
vesicular. There was no cough and no expectoration.
The nails showed checking of growth in a ridge running
across the nail at about one-third the distance from the mat-
rix to the free border. He was ordered turpentine stupes,
quiuia (gr. xij) daily, and a mixture containing gtt. v of the
tincture of digitalis and gr. x of the citrate of potassium every
four hours. The impulse of the heart was moderately ex-
tended, but not forcible. The first sound was murmurish and
soft, but there was no murmur.
November 3d. Physical characters much the same; still
no cough. There is impaired breathing, and some fine
rales can be heard at the right base posteriorly, with some
loss of resonance. The dullness on the left side is clearing
up; the respiration anteriorly is rather exaggerated; th*
amount of whiskey increased to f vj daily.
November bth. Decided dullness at right base posteriorly,
with signs of pneumonic consolidation of lower half of lung.
The left side is clearing. Ordered carbonate of ammonia (gr.
x) every three hours.
November 7th. Considerable dullness of right side ante-
riorly ; is troubled with hiccough upon the slightest exertion ;
this continues nearly all night; has a slight cough occasion-
ally ; he is restless at night.
Treatment continued ; blister to right chest anteriorly ;
spirits of chloroform (f3j) administered four times a day;
takes ten ounces of whiskey daily; tongue coated and dry ; no
cardiac murmur ; a little faint crepitation at base of heart, but
the patient's condition prevents him from holding his breath
for the purpose of accurate diagnosis.
November 8th. Tongue tremulous ; has a little dry cough
and troublesome singultus. Ordered plenty of milk, beef-
tea, eggs, &c.
November 9th. Looks better, but still very weak ; still
considerable dullness over the upper part of the right lung,
where respiration is imperfect and feeble, with slightly pro-
14 Notes of Hospital Pradics..
longed expiration. The whole condition seems to give the
idea of non-expansion or of collapse. The pulse has better
volume; tongue cleaner, moister and slightly coated, but is
less typhoidal in its appearance. There is less hebetude.
November 11th. Hiccough better; still taking ten ounces
of whiskey daily, and carbonate of ammonia every two hours ;
respiration rather feeble at the right base, with coarse crack-
ling above it ; tongue rather dry, with white coating, but less
dry than before ; no albuminuria. Basham's mixture (f. | ss. s.
t. d.) now ordered. There is some effusion at the right base.
November 12th. Twitching of the facial muscles in sleep;
respirations 23 in sleep and 36 awake ; has very little hiccough
at present.
November 13th. Better to-day than yesterday ; appearance
brighter; urine normal; pulse has rather more volume; there
is a sound of friction at the right base.
November 14th. About the same ; temperature rather high ;
respiration quite feeble, with some prolongation of respiratory
murmur at the right apex, with still some dullness; fremitus
on right side feeble ; the evidence of effusion at the right base
persists. Whiskey increased to f. i viij, and Basham's mixture
given four times daily ; quinia, gr. xvj, daily, and carbonate
of ammonia, gr. x, every four hours.
November 15th. Impulse at apex of heart is not in the
normal position, but is a little outside of the linea mammalis ;
the sounds are indistinct, yet well defined ; the heart is dis-
placed by pressure from the right side, but its beat is distinctly
felt ; the lower part of the right lung moves a little in respi-
ration. Ammoniae carb. to be stopped, and Basham's mixture
to be given every three hours.
November 18th. Is passing water freely ; apparently im-
proving ; respiration, though feeble at the lower part of the
right lung, is again distinctly vesicular and is less dull, but
there is still impaired resonance at the right apex ; the apex
beat of the heart retains its distinctness, and is seen as well as
felt \u the sixth intercostal space, one and one-half inches to
General Diseases. 15
the outside of the nipple; a slight quiver can be seen in the
space above ; there is slight friction at the left base ; respira-
tion well sustained on the left side, low down, but it is rather
harsh.
Died this afternoon.
A post-mwtem examination reveals an immense effusion in
the right chest, with condensation of lung by pressure ; heart
pushed to left ; no active sign of pneumonia.
In the ileum were found patches of Peyer in an ulcerated
condition, one having sloughed out, leaving the sub-mucous
coat with a healthy, granulating surface. Dr. DaCosta.
INDICATIONS AGAINST PARACENTESIS THORACI8.
The case had been in the wards for some time, with the
history of an attack of pleurisy following exposure. When?
the patient was first admitted in November, examination
revealed an old right-sided pleurisy, with some evidence of
abscess of the right lung. Subsequently the signs of pleuritic
effusion developed rapidly, and it was very evident that there
was considerable effusion in the lower part of the chest.
The question which arose was whether, with the evidence
of a right-sided pleurisy, which remained rather stationary,
together with the suspicion of tuberculous disease, resort should
be had to aspiration, or whether the endeavor should be made
to get rid of the effusion by medicinal means. When the
patient was first admitted he had already had the effusion for
several months.
Upon thinking the case over, and considering the strong
probability of disease of the lung itself, though marked ; find-
ing also no marked irritative fever, and having, therefore, no
reason to suppose that the chest was full of pus, Dr. DaCosta
concluded to try and get rid of the effused serum by medicinal
means, and determined not to tap the chest. The result ju^t*
fied the conclusion reached.
On February 1st the dullness still remained low down in
16 Notes of Hospital Practice.
the right chest. The voice was transmitted from all other
parts of the lung. So, too, with regard to the vocal fremitus.
The breathing was also fuller and deeper.
The treatment consisted principally in the administration
of the tincture of the chloride of iron, with acetate of ammo-
nium. Occasionally a Dover's powder was given at bedtime.
The food was generous, and counter-irritation was frequently
made with iodine or blisters.
From the good results already shown, Dr. DaCosta was
confident that this treatment ought to be persevered in.
The patient was ordered in future a tablespoon ful of Basham's
mixture four times daily, and a tablespoonful of cod-liver oil
thrice daily, on account of the suspected latent disease of the
lungs.
The case was regarded as proving that it is never wrong in
old cases of pleural effusion to give a fair trial to medicinal
means first, and never to try tapping until we are quite sure
that all other modes of relief are of no avail.
The three points particularly suggested and emphasized by
the case were (1) that we should be guided rather by the
effects of an effusion than by the time it has lasted; (2) the
value of Basham's mixture and repeated counter-irritation in
the treatment of chronic pleurisy ; (3) the possibility of tuber-
culous disease of the lung as a co-existent factor is always an
additional reason for not tapping, since surgical interference
should never be attempted when this complication exists.
PNEUMONIA.
The routine treatment of pneumonia in the wards of the
Pennsylvania Hospital consists in the internal administration
of from eight to twelve grains of quinia daily, together with a
moderate amount of nitrate of potassium and of the tincture of
digitalis every two or three hours. Plenty of stimulus is ad-
ministered. In a case recently under treatment, Dr. DaCosta
gave in place of the nitrate of potassium a teaspoonful of the
General Diseases. 17
jpirits of ammonia in water every three hours, as an alkali.
This use of ammonia (as an alkali) was so successful in Dr.
DaCosta's hands that Dr. Hutchinson tried it in one of his
eases with equally good results.
THE TREATMENT OF ORGANIC HEART DISEASE.
In those instances where there is a maximum amount of
cardiac force, with a minimum amount of valvular lesion,
cardiac sedatives are regarded by Dr. Pepper as the remedies
par excellence. Veratrum viride, aconite, the bromide of
potassium, and other bromides are given in small and con-
tinued doses. The need of cardiac sedatives has been found
to be most marked in diseases of the mitral valve, where there
is a marked tendency to hypertrophy of the left ventricle;
In these cases the diet allowed is cooling and restricted ; cir-
culatory and nervous stimulants are avoided. If the general
system is plethoric a saline depurative is administered. The
diet, though restricted, is not reducing, i. e., the blood is not
reduced in quality by it, though it is of such a kind as to be
easily digested.
Where the valvular lesion has been the result of an endo-
carditis contracted in early life, it has often been found possi-
ble to accomplish the greatest amount of good by continuous
doses of the iodide of potassium. This treatment has often
cured young children with hypertrophied left ventricles and
mitral disease.
In those cases of heart disease showing impairment of power,
and occurring late in life, the most important item of treat-
ment is rest and the avoidance of all muscular effort. Such
patients are given beds on the ground floor and never allowed
to mount stairs. In bad cases rest upon one floor and in one
room is insisted upon.
The question of diet in the treatment of heart disease has
received unusual attention in the Hospital of the University of
Pennsylvania. The diet is studied in connection with the state of
18 Notes of Hospital Practice.
the system. When the digestion is good and the blood not in
abundance, the patient is allowed bread, meat, fruits, and green
vegetables quite freely. Some such patients have been bene-
fited by a lean meat diet. No patient in this condition can
digest oil well. In those cases where the digestion is not
good, koumyss, buttermilk, or skimmed milk is given. Where
the secretions are scanty and dropsy is present, the diet pre-
scribed is exclusively one of milk. Such patients are not
allowed to eat much at a time, but take food frequently and
in small quantities.
Where spasms of cough and of dyspnoea occur at night, the
patient is only given a small amount of stimulus and liquid
nourishment for some hours before going to bed.
(To return for a moment to the question of rest. In some
mild cases of heart disease, gentle, moderate walking is
strongly advised, but in no instance is needless running hither
and thither allowed.)
For the relief of the various congestions consequent upon
heart disease, counter-irritants are applied over the affected
part. Where nervous and head symptoms predominate, dry
cups are applied to the nape of the neck. In pulmonary con-
gestion, muriate of ammonia is given internally in addition to
the external counter-irritation. The bromides are used in
cerebral congestions. When the stomach is congested, blue
mass is prescribed.
When the appetite is poor, the stools insufficient, the liver
tender upon palpation, and the secretions of the intestines
scanty, blue pills, followed by a saline laxative, is a favorite
remedy. Renal congestion is put a stop to by digitalis, to-
gether with a saline diuretic.
When the system is in an ansemic state, when the blood is
watery, and when it is deficient in red globules, iron is given
with advantage. Active plethora is always regarded as a
counter-indication to the use of iron. The iron, when given,
is administered in the form of a laxative ferruginous water,
or a diuretic ferruginous mineral water.
General Diseases. 19
In the treatment of the various dropsies complicating heart
disease, cups, blisters, iodine painted on the surface, or iodine
with croton oil is used.
In some cases the dropsy is entirely cured by rest and a
skimmed-milk diet.
In cases of anasarca the most rapid relief is obtained by the
use of jaborandi. Where the heart is so weak that jaborandi
cannot be used, resort is had to laxatives, or warm vapor
baths.
Ascites is met by saline diuretics ; hydrothorax by diaphor-
etics and diuretics. The patient's whole body is periodically
examined physically, to see that no effusion is gaining head-
way.
If the dropsy becomes otherwise unmanageable, resort is
had to operative measures, and the skin is tapped a number
of minute punctures being made in the skin with delicate
needles.
Where there is a faulty condition of the nervous ganglia of
the heart, associated with the organic disease, digitalis is em-
ployed with great benefit. Where one preparation of this
drug is not borne by the stomach, another is substituted.
Where the separate contractions of the heart are evidently
inefficient, and the pulse is weak and small, digitalis has
proved itself an unrivaled remedy. The usual dose of the
tincture is gtt. x; of the infusion, f 3j ; and of digitalra, gr,
J/60 every three hours.
Belladonna has been of service where the heart's action is
strong but irregular. Where the heart muscles are weak and
passive congestions rife, strychnia and quinia are prescribed.
ALBUMINOID DEGENERATION OF THE KIDNEYS OF PROBA-
BLE SYPHILITIC ORIGIN, WITH OZ^NA AND PSEUDO-
MEMBRANOUS ANGINA.
The patient was a white man, thirty years of age. When
admitted to the hospital he presented the following history-
20 Notes of Hospital Practice.
He had been engaged in the manufacture of morocco for tlu
past fourteen years, with the exception of three years spent in
a butcher's shop. His habits had been good, always, except
when butchering, when he was intemperate. He had always
been a hard-working man, and had been constantly exposed
to coid and wet. He had variola and measles Avhen a child,
but no other exanthematous disease. He was a married man,
and had one child, who suffered constantly from oedema of
the feet, and face. His (the patient's) father died of paralysis
of syphilitic origin, and his mother of dropsy. His only
living brother was healthy, but his sister had goitre, palpita-
tion and dropsy.
During the twelve months prior to his admission the patient
had had frequent pains in the back and frequent dyspnoea.
During the last four months of this time there had been a
general condition of anasarca.
The appearances presented by the man upon admission
were as follows: His face, neck, feet and body were swol-
len. His general aspect was markedly anemic. He was de-
cidedly drowsy, but his intellect was good. His tongue was
tremulous, coated, and flabby, and there was a membranous
patch upon his uvula. The tonsils were enlarged, and the
throat sore. The man's appetite was good, but there was
considerable flatulence and pyrosis after meals. His bowels
were somewhat costive. Respiration was attended with a
loud noise in the larynx. Expiration was prolonged. The
glands on the right side of the neck were swollen. He had a
bad taste in his mouth, and his breath had an unpleasant
Bmell. There was no abdominal effusion, and his lungs
seemed to be healthy. The sounds of the heart were distant
and feeble, and the pulse was small and rapid. The apex-
beat of the heart could be felt underneath the rib in the fourth
interspace ; a weak impulse could also be felt in the second
and third interspaces at the border of the sternum. The
upper border of cardiac dullness was a line drawn from the
head of the second rib to the left nipple, and its utmost limit
General Diseases. 21
outwards was a line drawn directly downwards from the nip-
ple to the fifth rib. A line drawn parallel to the linea mam-
mal is and running from the fifth rib to the xiphoid cartilage
represented the lower border of cardiac dullness, while its limit
on the right was the median line of the sternum. The urine
passed was dark red in color, and of alkaline reaction, and
amounted to sixty-four ounces in the course of twenty-four
hours. The contained albumen formed fully one-half its
bulk. Its specific gravity was 1006. It contained many
granular and hyaline casts.
Dr. Pepper regarded the case as one of a very curious and
interesting nature. It was concluded that the kidneys were
the seat of albuminoid degeneration, with catarrhal nephritis.
The underlying constitutional taint seemed to be undoubtedly
syphilitic. It was argued that the angina was an outcome of
the systemic disease, but that the ozsena was presumably a
manifestation of the catarrhal nephritis.
The case was regarded as an excel lent example of those cases
of hereditary syphilitic infection in which the poison is so diluted
and the patient's constitution so robust that the disease does
not show itself until well on towards middle life.
The indications for treatment were thought to consist in (1)
the removal of the dropsy by large doses of jaborandi, and (2)
in a nourishing and easily digestible diet. Buttermilk, oat-
meal gruel, and light broths were ordered as foods.
After the dropsy had largely disappeared minute doses of
the bichloride of mercury, with the iodide of potassium, were
administered ; at the same time cod-liver oil was given in
combination with the iodide of iron. The patient was much
improved.
IDIOPATHIC PERITONITIS.
If the case is brought into the wards at the very inception
of the disease, the patient is bled thoroughly from the arm.
If the disease is of many hours standing, Dr. Wood has the
22 Notes oj Hospital Practice.
abdomen covered with as many leeches as it will hold. After
venesection, calomel is administered in doses of from one-
quarter to one-half of a grain every hour. In connection
with the calomel, opium is given in large doses. Opium in-
duces quiet and prevents the exhaustion consequent upon hor-
rible physical pain. Enough opium is given to keep the
patient on the verge of narcotism. It had better be given in
liquid form.
In the latter stages of peritonitis, blisters are always em-
ployed.
The first thing done, however, when the leeches have been
removed, is to apply poultices ; whether they be hot or cold
makes but very little difference. Where there is a very
marked tendency to feverishness, cold poultices are used. If
the abdomen is too tender to bear the weight of the ice-bag,
light flannel cloths wrung out of ice-water may be used. On
the other hand, a warm-water dressing may be employed with
advantage in very many cases. Warm water acts not only as a
local derivative, but some of it probably oozes through the
intervening tissues into the abdomen, and so acts directly upon
the inflamed peritoneum as a soothing agent.
After the abdomen has been thoroughly poulticed for two
or three days, blisters are used, provided the temperature of
the body has not remained high. The blister should not be
a small one eight inches by ten makes a very good size.
When there is any septic element in the disease, quinia is
used with great benefit. Generally the stomach is not strong
enough to bear it.
The patient must have but very little food in the first few
days of the attack. The food which is given is that which
leaves the least residuum of undigested matters, and therefore
causes the least amount of peristaltic action on the part of the
intestines. Milk, in repeated small doses, is the food usually
given. At the end of a few days, solid articles are allowed.
When there are symptoms of exhaustion late in the course of
the attack, beef-tea is given as a stimulant. Alcohol is not
General Diseases. 23
only powerless, but even dangerous in the early stages of the
disease. A few doses of brandy in the first few days of an
attack of peritonitis may produce death.
With regard to the opening of the bowels during conval-
escence, a purgative or an enema is never used. These bring
violently into play all the muscles of the abdomen. Very
often there will be a spontaneous movement on the fifth or
sixth day without any medicine at all. If there is not such an
opening, a small dose of castor oil is given at the end of ten
days. If there is retention of urine, the water is, of course,
drawn off by means of the catheter.
Great care is had during convalescence from peritonitis to
prevent a relapse. No violent or gymnastic exercise is al-
lowed for a long time afterward.
TWO INTERESTING CASES OF VOMITING.
CASE I, eet. twenty-five. Family history not good.
Sister and father both died of phthisis. She herself was
always healthy. Began to menstruate at age of seventeen and
stopped menstruating at twenty. Since then the menses have
been very irregular. She married at the age of eighteen and
was a widow at twenty-one. You will, therefore, notice that
the irregularity of menstruation has existed not only during
marriage, but also before and since.
She comes into the hospital for the treatment of what is
apparently a very serious difficulty, viz., she has been vomit-
ing constantly for nearly a year. She has been in the hos-
pital for only a week. She has been vomiting incessantly ;
has never retained more than one meal during the course of
the day for the past year. The vomiting always begins the
instant after her meal is over. She does not have much
vomiting or nausea between her meals.
A year ago she was stout and healthy, but the vomiting
has rendered her thin and pale. Though not so this morn-
ing, it is fair to state that she has picked up wonderfully
24 Notes of Hospital Practice.
within the last few days, and you will, no doubt, want to
know what has been done.
- In the first place, I had the vomited matter examined,
with but negative results. There were no sarcinse, nothing
but mucous mixed with the contents of the stomach. Occa-
sionally the patient has been disturbed by vomiting mucous
iu her sleep.
Together with the vomiting you notice that she has a slight,
irritative cough. This cough has troubled her ever since the vom-
iting began. Joined with the cough there is no expectoration.
Before going any further, however, I will examine the gas-
tric and intestinal organs. Her tongue is slightly coated and
.flabby, and there is some tenderness in the epigastric region
and along the spine, particularly at about the middle point of
the spine. There is, however, no appearance of a tumor.
The soreness in the epigastrium is general, and is not local-
ized in particutar spots. The bowels are constipated ; the
respiratory sounds are normal. There is no albumen or abnor-
mal ingredient in the urine. There is no fever, and the
temperature is normal. The urine is acid and of the usual
color, with a specific gravity of 1025.
What has been the cause of vomiting? What remedy is it
which has stopped the vomiting in three days ?
When I first saw the woman in the wards and heard of the
incessant vomiting, I first thought it was a case of irritable
stomach in a young woman, connected with gastric ulcer. The
epigastric soreness, the age of the patient, the appearance of
the tongue, the disordered menstruation, the sore point in the
spine, all tended in that direction.
I soon gave up the idea, however. Gastric ulcer gives rise
to local soreness; here the soreness was general. Gastric
ulcer is attended by hemorrhage and pain upon taking food,
which was not the case here. The two most prominent symp-
toms of ulceration were absent. I rejected the idea.
Then there came up a point of experience in my mind
one case similar had happened not long since in my own prac-
General Diseases. 25
tice ; several I had seen in consultation. In one case the
vomiting had reduced the patient almost to the verge of the
grave; nothing stayed on her stomach. In her case the irrita-
tion was reflected upon the stomach from a uterine malady a
slight flexion. It was not very different from the sympathetic
vomiting of pregnancy. Moreover, there was in that case a
certain amount of gastric disease a catarrhal affection of the
stomach came on as a complication of the nervous affection.
In the light of that experience I began to suspect the same
condition here. As a result of examination we found retro-
flexion of the uterus. The whole case was cleared up at
once. It was reflex vomiting with a certain amount of gas-
tric catarrh, lasting for a year, although the woman had
taken the greatest care with her diet, etc.
When she was first admitted she was put upon lime-water
and milk, but there was no effect produced upon the vomit-
ing. How did we check it? It was not by diet alone.
Again experience came to my assistance, and I determined
to try the application of ice to the spine as a systematic treat-
ment, every few hours. The ice was applied and left on
until it chilled the patient and made her skin cold. The
application was often repeated as often as she could bear it.
Its effects were admirable. No other treatment was neces-
sary. The vomiting stopped almost at once.
You will not always be so successful with this remedy
alone. Is there nothing which we can combine with the ice
must we depend upon it alone? By no means. Bromide of
sodium in doses of ten or fifteen grains thrice daily is very
effectual. It lessens the reflex irritation, and is not rejected
by the stomach. An occasional purge by an enema, or some
bitter-water, is often desirable. Subsequently, if the case
lingers, use blisters to the spine. Do all this irrespective of
the local uterine treatment, for the reduction of the uterine
displacement will not always stop the vomiting at once the
cause is removed, but not the habit.
To-day I shall introduce a pessary. Already the girl's
26 Notes of Hospital Practice.
diet has been increased, and she is beginning to retain solid
food.
What else can we use in such cases to soothe the stomach ?
Pepsin is very valuable as soon as the vomiting has been
stopped. The dose of saccharated pepsin is five grains thrice
daily. The diet all this while should be gradually increased ;
only small quantities of food being given, but these fre-
quently.
This condition is very similar to hysterical vomiting.
There is no manifestation of hysteria here. The two states are
parallel, but not identical. In an hysterical case the results
of treatment would not be so good.
CASE II, set. fifty-five, single, comes of healthy family.
Her own health has not been bad considering her age and
occupation that of cook. She has suffered from dyspepsia
for a long time, together with flatulence and constipation.
She is also a sufferer from sick headache, and from a certain
amount of pain in her stomach.
Some time after these symptoms appeared, her abdomen
began to swell and became painful. She vomited ; on two
occasions vomited blood. Her general health at the same
time has failed, and she has lost flesh, and is, as you see, very
pale and anemic. This morning she vomited blood for the
third time.
The treatment shall be based (1) upon the haematemesis,
and (2) upon the general gastric symptoms. Since she has
taen in the hospital she has vomited every day. Attending
this vomiting there has been a burning pain in her stomach.
This pain is not always increased by taking food, and often
existed apart from the hours of her meals.
The vomit, a specimen of which I here show you, consists
of black coagula coffee-grounds the usual character of the
vomit of cases of haematemesis. The attack of vomiting
which she had this morning has rendered her pale and weak.
The disease is plainly shown, by the character of the vomit,
to bf situated in the stomach ; is probably gastric ulcer.
General Diseases. 27
Her temperature has risen to 100, her pulse is feeble and
compressible, there is general soreness over the epigastric
region, the tongue is dry and but slightly coated. The
woman is scarcely in a condition for me to attempt an accu-
rate and minute examination and diagnosis. When the gas-
tric hemorrhage is over, it will be very easy to make out the
gastric condition; indeed, I have already told you what I
believe it to be.
As regards the treatment of the hsematemesis, the most
effectual remedy is the hypodermic injection of Tf[,x of the
fluid extract of ergot the minute that the bleeding begins.
This injection should be repeated if the least symptom of
return of hemorrhage appears. We shall keep up this
woman's strength by means of such food as eggs, milk, beef-
tea, etc., by enema. If there is any sign of heart- failure,
brandy is, of course, necessary by enema. Lastly, I shall
order several small blisters to be placed over the epigastrium.
In this way you see that we are treating and nourishing the
patient without putting a drop of anything in her stomach.
Should this treatment not be successful, I should order f^x
of turpentine and gr. l/ 2 4 of morphia in emulsion, by the
mouth, every third hour. Dr. DaCosia.
GRAVES' DISEASE.
In the treatment of this disease Dr. Pepper gives the
greatest care to the removal of the causes, and towards secur-
ing rest, good food, change of scene and entire release from
care. The various functions are attended to, and any local
disorder in females is removed by suitable treatment. Digit-
alis has been found to be the most valuable remedy for con-
trolling the functional disturbance of the heart. It is given
freely, in doses of from ten to fifteen drops, three or four
times a day, and continued for long periods. When anaemia
exists, large doses of iron are administered. Most excellent
results have been obtained from the injection of diluted solu-
28 Notes of Hospital Practice.
dons of ergotina into the enlarged thyroid gland. The
needle is introduced to the depth of half an inch or an inch,
and from six to ten minims of a solution containing 96 grains
of ergotina to the f 1 j of distilled water was injected. Bromide
of potassium has been found to assist the iron and ergot in regu-
lating the action of the heart.
INFLAMMATIONS OF THE NASAL PASSAGES, EUSTACHIAN
TUBES AND MIDDLE EAR.
A solution of zinc is applied through the catheter. To do
this, the catheter is first introduced, and then three or four
minims of a solution (3/ 5 gr. to the f lj) of zinc are dropped
into it. The zinc is forced through the catheter into the ear
by means of Politzer's bag. In some cases nitrate of sil-
ver is applied to the diseased surface by means of a post-nasal
syringe introduced behind the soft palate. In old cases of
catarrh of the middle-ear, where the secretions have ceased,
the attempt is often made to stimulate the membrane. This
is done by means of ether. From 8 to 10 gtt. of ether
are dropped into Politzer's bag. The patient takes some
water in his mouth, and holds it there. A nose-piece is put
in his nose, and just as he is swallowing the water, the ether
is squeezed through the nose-piece into the passages.
With regard to constitutional measures : where the disease
has been hereditary, and has run through many generations,
the case will only go on from bad to worse, unless something
be done to bring up the general tone. If there be any stru-
mous diathesis, the bichloride of mercury is given internally
for a long time, and in small doses.
Dr. George Strawbriclge regards the following as a good
form of administration of the drug :
R Hydrarg. chlo. corrosivi gr. 3^.
Elix. cinchonas f^ 68 * ^
SIG. To be taken two or three times a day, after meals.
General Diseases, 29
Iron and strychnia are given in pill form. In old
people, where there is very decided lessening of the secretions,
ten-grain doses of the muriate of ammonia are given thrice daily.
Before administering this dose it is dissolved in f3j
of the elixir of cinchona, and this again suspended in half a
pint of acid water. Muriate of ammpnia, like iodide of potas-
sium, is never administered to the stomach unless in a highly
diluted state.
THE NIGHT-SWEATS OF PHTHISIS.
" I have treated the night-sweats very successfully in this and
other cases with granules of atropia 1/gQ to 1/60 of a grain
every night before retiring. This atropia treatment was first
started at the Pennsylvania Hospital, and it has been very
generally adopted elsewhere, as the best means of checking
colliquative sweats, both in phthisis and in other affections;
after taking from I/go to 1/gQ of a grain of atropia every night
for four or five nights, the sweating is usually entirely checked.
It has been objected to this atropia treatment that it produces
great dryness of the throat. I have endeavored to counteract
this effect by the use of strong lemon-juice, lemonade, gum-
water, or slippery elm conjointly with the atropia. Quite re-
cently I have obtained the very best results by means of
jaborandi combined with the atropia. The doses of jaborandi
must be exceedingly small. I have not yet made trial of this
combination in a sufficient number of cases to enable me to
make an authoritative statement. All I can say is that I
have been able to produce entire toleration of the atropia in
every case in which the jaborandi was combined with it. The
atropia checks the great drain of the sweats upon the system,
and so gives the other remedies a chance to act." Dr. J. M.
DaCosta.
30 Notes of Hospital Practice.
CONTAGION IN SCARLET FEVER.
On April 30th, 1878, a very severe case of scarlet fevei
appeared in the boys' ward of the Children's Hospital. The
boy attacked occupied a bed near the centre of the room.
Coincident with this was a similar case in the girls' ward. Both
of these wards are on the second floor. The cases were at once
removed to the upper story, where wards are prepared for such
contagious diseases as arise among the house patients.
Within a week previous to his removal this boy had been
successively changed from two beds to a third, and immedi-
ately afterwards these two beds had been occupied by
other boys. No other case occurred in either of these wards.
In a ward on the third story, front, were a number of chil-
dren suffering from whooping-cough, a disease which had run
riot throughout the house, but was then upon the decline.
The ward adjoining this was the one devoted to the scarlet
fever patients. Among the whooping-cough cases, on the 2d
of May, a girl manifested the characteristic symptoms of scar-
let fever, and was transferred to the adjacent ward. Not
another one of these cases of pertussis took the scarlet fever,
notwithstanding the fact that the girl already attacked, who
was well grown, and was suffering also from keratitis in addition
to the cough. She acted as nurses' assistant, and in this capacity
repeatedly came in contact with the other children in the
ward.
Ten days after the last date, on May 12th, two very mild
cases, occupying beds very remote from each other, broke out
in the back ward on the second floor. These last were so
faintly marked that they might have been overlooked but for
the suspicions excited by the prevalence of the disease. On
the 1st of June one other case occurred in this ward. On
May 4th another case occurred, a boy suffering from a slight
deformity, and confined to the "play-room," so-called a
room below the first floor, opening directly upon the play-
ground. The children from this part of the house seldom
Genera/ Diseases. 31
came in contact with those in the upper wards, and theii only
in exceptional cases. Twenty-four days after the isolation of
this last boy, one other case, that of a girl, occurred in the
" play-room."
From these facts it would seem that contagion is not
the most important element in the spread of this disorder.
We must rather look to individual susceptibility coupled with
similarity of circumstances. Nor has mere physical weakness
much to do with this susceptibility. Lying very near most
of the cases above mentioned were children suffering from a
great variety of troubles, both medical and surgical. Only
one or two in an entire ward were attacked. During the time
which elapsed from the incipiency of the first to the conval-
escence of the last case, between eighty and ninety general pa-
tients were treated in the house. Only nine of these took the
scarlet fever. Of all the patients in the house, but half had
had the scarlet fever. The first boy attacked had been in the
house seven weeks before the manifestation of the angina,
which, in his case, was unusually severe. He could scarcely
have come in contact with any one carrying the " seeds of the
fever" after entering the house. This case was by far the
most severe of all, resulting in death. None of the others
died. Each case was milder than the preceding one an evi-
dence that the most susceptible are those first attacked. To
but one case was there the sequela of albuminuria. This
child was also suffering from a severe bronchitis, and at the
outset of the fever was much emaciated. The presence of the
albumen was first detected on the nineteenth day. There was
little else to suggest danger, except a trace of blood in the
urine, Prompt treatment held this symptom in check, how-
ever, and by three weeks' time the blood and albumen had
both disappeared from the urine. The bronchitis meanwhile
was all gone, and the child improved in color and flesh.
Keratitis in two cases was much improved by the fever. Dr
James H. Hutchinson.
32 Notes of Hospital Practice.
PATULOUS AORTIC VALVE ACCOMPANYING CHRONIC
BRIGHT'S DISEASE.
The patient was found lying unconscious in the street.
When brought into the hospital his pupils were contracted
and his breathing stertorous. The radial arteries were very
tortuous. One-sixth of the bulk of the urine was found to
consist of albumen. The fseces were passed involuntarily.
Immediately upon admission the man was given gtt. ij of
crotou oil in a teaspoonful of olive oil, and a dose of the fol-
lowing prescription :
R Spts. chloroform! (B. P.) gtt. xxx.
Acid, benzoici gr. vj.
Potas. bicarb gr. xxx. M.
SIG. Drops ten every two hours, in water.
For sustenance the patient took three pints of milk and one
pint of beef-tea, together with f f j. of alcohol, the milk and
beef- tea being given in small quantities at short intervals.
Atropia was injected into the eyeball, but did not dilate the
pupil sufficiently to enable the visiting physician to examine
the eye-ground with the ophthalmoscope.
When examined carefully by Dr. John Forsyth Meigs, on
the day after admission, the right side of the patient's mouth
was found to be paralyzed. So, too, were the right arm and
right leg the leg less so than the arm. T'ie man was still
dull and inattentive. His respirations were 44 to the minute,
and his pulse 116. The radial arteries wound along like
worms, and pulsated visibly from the elbows to the wrists.
Another curious fact in connection with the case was the
presence of rounded, hard tumors on the back of his elbows
and over his phalangeo-metacarpal joints. One of these
tumors was opened, and a very thick, creamy matter escaped,
which yielded crystals of tyrosin under the microscope. It
was impossible at that time to detect any murmur of aortic
regurgitation.
In endeavoring to reach a correct diagnosis in the case, the
General IKseases. 33
visiting physician was led at first to regard the case as one 01
opium-poisoning, owing to the marked 2ontraction of the
pupils ; -but this view of the case was invalidated by the facts
of paralysis and stertorous breathing. It was finally deter-
mined that the case was one of chronic Bright's disease, and
the opinion unhesitatingly advanced that further examination
would reveal the presence of tube-casts, and that when the
more violent symptoms had subsided a regurgitant cardiac
murmur would be heard. Mention was made of the state-
ment advanced by Walsh, of London, viz., that the tortuous-
ness of the arteries present in the case is only present in
patulous aortic orifice and coarctation of the aorta.
Subsequent events proved this diagnosis to be the correct
one.
The patient's comatose condition, dependent upon the
ursemic poisoning, was found to yield very markedly to the
following prescription, recommended by Dr. George Johnson,
of London, viz. :
Scammonii resinse ~ gr. v.
Potassii bitart gr. xx.
Zingiberis .. gr. viij. M
Sio. To be administered when needed.
RHEUMATOID ARTHRITIS AND CHRONIC ECZEMA.
James Talbot, white, set. 41, iron worker. Admitted
July 30th, 1874. Twenty years before that time he went
to the Isthmus of Panama in charge of a storehouse, and
remained there four months, during which time he contracted
Panama fever, consisting of chills, fever and night sweat, fol-
lowed by general debility. He returned to Philadelphia very
much reduced in health and has never since recovered from
the effects of this disease. Fifteen years ago he was attacked
for the first time with inflammatory rheumatism, beginning
suddenly in the feet and extending thence to the various other
joints of the body. He was confined to bed for nine months,
34 Notes of Hospital Practice.
the feet, ankles and hands enlarging and becoming painful.
He remained in a partially crippled condition for five years
being better and worse from time to time. Seven years ago,
while at work excavating a well, he was again attacked with
rheumatism, accompanied by great pain in the joints and by
general stiffness. Upon this occasion he kept his bed for
fifteen months and experienced a most severe attack. He
never recovered entirely from this illness, and found himself
becoming more and more involved from mouth to month.
Three years ago the disease had increased to such an extent
that he was forced to stay in his bed permanently. His feet,
hands, and all the larger joints were greatly swollen and dis-
figured. He now began to get steadily worse, both as regards
deformity and suffering. The rheumatic symptoms all became
more marked and showed no disposition to leave him. He
became entirely unable to use any of his joints and even to
turn in bed. He has been on his back for the last two years.
During this time he has gradually lost flesh, notwithstanding
that his appetite has been good. His bowels have been con-
stipated. He has never had any skin disease of any kind
until one 'year ago when his present trouble began to show
itself on his right foot, around the back of the foot and on
the instep. The left foot soon became similarly affected.
Later the hands and arms were attacked, and by degrees, in
the course of six months, the trunk became involved. Patient
states that the eruption started about the large toe nail, which
loosened and came away, and was followed by a crust formation.
These crusts came off from time to time leaving a reddish,
discharging surface, and finally all the toe nails became de-
tached. At this time there was no itching, but about eight
months ago itching began and was most severe about the legs
and arms.
Present condition. The skin of the face, scalp, shoulders,
arms, abdomen, penis, legs and feet, is involved in a low
grade of eczema. The disease is diffiused in patches of vari-
ous sizes, and is most marked upon the lower extremities. The
General Diseases. 35
skin is boggy and red, giving forth a copious secretion of liquid
with a certain amount of blood, which dries, forming exten-
sive crusts. On some parts of the feet there is maceration
of the epidermis, showing the rete mucosum in an exposed
state. The nails of the toes are all in a soft, broken-down
condition and loosely attached to the matrix. Upon the
calves of the legs are small, abraded patches of papular eczema.
The knees also are similarly affected. About either side of
the throat at the anterior termination of the ribs are two
patches of inflamed skin, resulting from the constant pressure
of the hands upon these parts. The hands and fingers are
covered with large, yellowish crusts, which can readily be de-
tached, exposing beneath a soft pulpy substance, from which
serum and blood constantly ooze. The skin upon the other
portions of the body is more or less shriveled, dry and scaly.
A very low state of vitality of the cutaneous surfaces is every-
where to be seen. Patient lies upon his back and is unable
to move from this position. The thighs are flexed upon the
body and the legs upon the thighs. The joint trouble and
the contraction of the tendons fixes the limbs in this position.
The feet are everted to almost a right angle with the legs, and
are immovable. The arms are fixed across the abdomen. The
left hand abducted and fingers immovably flexed. The right
hand is less markedly distorted, and the fingers are extended.
The lower jaw is almost fixed and he is unable to masticate
anything solid. Appetite good and is in good spirits. Urine
has a specific gravity of 1015, and contains red albumen or
sugar. He sleeps pretty well, but is kept awake during the
early part of the night by pain in the joints and limbs. Res-
piration 16, pulse 84. Bowels constipated, was ordered pulv.
aloes, gr. j ; ext. colch. comp., gr. j ; ext., hyoscy., gr. ss., at
night, and his body to be washed with castile soap and water,
and then sponged with liq. picis alk. f 3 to Oj, iind also an
ointment of acid, carbol., gtt. x, ung. zinc, benzoat., f ij, to be
applied after the tar wash.
Aug. 8th, 1874. Has been steadily improving as regirds
36 i Notes of Hospital Practice.
the eruption, healthy skin in extending all directions, particu-
larly upon the feet, where its advances can be daily noted.
Had a despondent nervous attack yesterday. Bowels not
moved for three days, so repeated laxative pills. One or
more of the joints are moved daily by the nurse. Patient is
taken out upon his bed into the open air for an hour or more
a day, according to his condition, weather permitting.
Aug. 28th. Prostrated somewhat by a nervous attack.
Pain in limbs, more motion than formerly, skin improving,
steam bath administered in bed and continued twenty min-
utes. Pulse increased from 88 to 115.
Sept. Sth. Steam bath to lower limbs.
Sept. 22d. Slept comfortably ; better than he has been for two
years. General condition improving. Omit tar alkaline
wash. Decidedly more motion in joints than formerly.
Oct. 1st. Eruption changing from squamous to papular
and vesicular, particularly upon the lower limbs.
Oct. 7th. Some little improvement, appetite good. Con-
tinue the same treatment and diet, milk punch daily, and ale
in evening. External application of green soap and alcohol.
Complains of soreness and stiffness in jaws on account of
taking ct)ld, some increase in number of blebs on legs.
Oct. 14th. Motion of joints improving. Blebs not quite
so numerous.
Oct. 29tli. Decidedly better. Legs and feet much im-
proved, ordered ol. morrhuse, f 3ss., t. d., and stopped potas.
iod. mixture.
Nov. 9th. Ordered a pill of ferri proto. carb. ; gr. ij, pulv.
glycr., gr. ij ; sacc. alb., gr. iv., t. d. Also an ointment of
amyl, iij, zinci ox., iiij; hydrarg. chlor. mit., 3 iv, to be
applied to limbs and body night and morning.
Nov. 18th. Blebs very numerous and confined to the calves
of the legs. This increased quantity of blebs seems to con-
tradict the idea that they are caused by the potas. iod., for that
medicine was discontinued long since. Ordered the iron pow*
ders to be stopped.
General Diseases. 37
Dec. \st. No improvement. Ordered tr. ferri chlor., gtt.
V, in liq. pot. arsenitis, n\j, thrice daily.
Feb. 2d, 1875. Patient has been no better for last two
months. Feet almost in same condition. No material change
except a little lessening in number of bullse.
Feb. 2'2d. Pain in joints is very severe now. No change
in condition of skin.
Mar. 15th. Use tar ointment on feet and legs. Stopped
the ointment of calomel.
April 25th. No change. Ordered a prescription of hydrarg.
chlor. corros. and alcohol.
Aug. 24th. Discharged to-day unimproved. For the past
two months he has been taking little or no medicine, and there
has been no change in his condition. About August 1st, 1878,
he died in another hospital in this city. Dr. Louis A. Duhring.
DILATATION OF THE STOMACH.
The endeavor is made by Dr. Cohen to produce contraction
of the walls of the stomach by washing out the ingesta with
the stomach-pump, and then rinsing out the stomach with a
solution of some disinfectant. The double effect is thus had
of cleansing and gymnastic exercise. In inserting the stom-
ach-pump the head of the patient is turned back, and the
tube is passed down the oesophagus over two fingers placed in
the mouth as a guide. This treatment by the stomach-pump
is persevered in for a long time. The stomach is well rinsed
)ut at each sitting. To get rid of remnants of food, emetics
are employed. The patient's general tone is sustained by
tonics.
. ACNE ROSACEA.
Dr. F. F. Maury treated this condition by the local applica-
tion of a mercury plaster. The alimentary tract is kept thor-
oughly open by a methodical course of salines, such as Epsom
38 Notes of Hospital Practice.
and Glauber salts, and Crab Orchard and Hunyadi Janos
water.
In addition to the mercury plaster as a local application,
the following lotion was ordered for the face :
R Sulphuris sublim sjij.
Etheris 3uj-
Vini frumenti q. s.
Ft. lotio.
The patient was advised not to drink anything but a little
red or white wine, and to be careful to refrain from fish and
too much meat.
TINEA FAVOSA.
The hair is first pulled out by the roots, the parasites killed,
and the scabs poulticed. Before beginning to pull out the
hair, however, the whole head is closely shaved. The separ-
ate hairs are pulled out with delicate tweezers. These hairs
are pulled out in their long axis, otherwise they would be
liable to break off short. The poultice is applied immedi-
ately after the hairs are pullcxl out, so that the pustules may
be well softened. After applying the poultice some parasiti-
cide such as the iodide of sulphur, or the bichloride of mer-
cury is rubbed in. The parasiticide most frequently used by
Dr. J. Solis Cohen is that formed by adding gr. ij of sulphur
iodide to i of lard.
SCIATICA.
i .
In Dr. Bennett's hands hypodermic injections of one-
eightieth of a grain of atropia and one-eighth of a grain of
morphia directly into the substance of the affected muscle
have always afforded immediate relief, although this relief, as
a usual thing, is only temporary. In cases of sciatica Dr.
Starr has injected the one-eightieth of a grain of atropia intc
the tissues directly over the track of the painful nerve with
manifest benefit. Dr. Wharton Sinkler, in several cases of
General Diseases. 39
local rheumatism, has tried the local injection of ether gtt.
x in water. Though this injection generally relieves the
pain, yet it is of itself always a most painful operation, owing,
no doubt, to the local irritation caused by the ether.
"When there is distinct local inflammation I am accus-
tomed to treat the disease with large doses of iodide of potas-
sium and minute doses of the bichloride of mercury. As
there is not much pressure exerted upon the nerve-trunks in
this case, the iodide of potassium will suffice. If we desire
to cause absorption of inflammatory matters inside the sheath,
the best way to do so is by means of severe blistering or by
the use of the actual cautery. The actual cautery, in particu-
lar, has great absorbent action, and powerfully relieves over-
sensibility of the nerves. In this present instance I have
been using the actual cautery with the greatest success at the
points where the pain has been most marked. Another excel-
lent treatment is by hypodermic injections of morphia and
atropia right down into the adjacent muscular structures.
For this purpose we are in the habit of using here from one-
sixth to one-fourth of a grain of morphia and from one-nine-
tieth to one-sixtieth of a grain of atropia. In employing this
formula you must be careful as the disease subsides that the
opium habit is broken. Indeed, the formation of such a
habit should be guarded against by intermitting the treatment
from time to time. In still other cases, again, Avhere the
localized pain has been intense, I have derived most excellent
results from the hypodermic injection of from eight to twelve
minims of chloroform, taking great care to keep the needle
out of the way of the arteries. Though incomparable as a
temporary destroyer of pain, the effects of the chloroform are
not very permanent. Before leaving the subject I may refer
to the use of electricity in these cases. Galvanism is very
quick, in some instances, to relieve pain. The mode of appli-
cation should be with the positive pole at the seat of the pain
and the negative pole along the nerve-trunk. Where the
muscles have wasted to any great extent the faradic current is
40 Notes of Hospital Practice.
the best. By some of the above-mentioned agents you wil.
generally be able to cut short the course of the disease." Dr.
Wm. Pepper.
HAEMOPTYSIS.
Dr. Starr has injected hypodermically from two to three
drops of the fluid extract of ergot in this condition with most
excellent effects, always rapidly stopping the hemorrhage.
SACCHARINE DIABETES.
The diet upon which a diabetic patient is placed consists,
for breakfast, of eggs, and any kind of meat, except oysters, glu-
ten bread, and tea or coffee, with milk and without sugar ; for
dinner, tomatoes, lettuce, onions, spinage, string beans, meat,
light sour wine, and lemons, or, perhaps, oranges, but none of
the sweet fruits; for supper, about the same as for breakfast.
None of the starchy foods, no alcohol, and no sugar are
allowed.
Among drugs, opium is considered the most valuable by
Dr. Pepper. Of this an immense amount can be taken daily,
it has been found, without producing any of the symptoms of
poisoning. One patient with this disease took seven grains
of opium per day. In this case the only bad effect was the
production of obstinate constipation. In some cases, even
this was unnoticed. The opium, by directly diminishing all
the secretions, or more probably by its action on the nerve
centres, relieves the excessive thirst and voracious appetite,
and reduces the amount of urine and of sugar in the urine.
In one case the daily amount of urine was reduced by the use of
this drug, from twenty-eight to eleven pints. Ergot, which has
been found to ad: in simple diuresis almost like a specific, is
used in saccharine diabetes with much profit, in doses of one
drachm of the fluid extract four times a day. Where the
skin is dry and rough, jaboraudi has been found to be of
General Diseases. 41
value, by reason of its great powers of diuresis. The opium
and ergot are stopped while the jaborandi is being used.
GASTRIC VERTIGO.
The best treatment has been found by Dr. DaCosta to con-
sist in regulating the diet and in the administration of bitter
tonics and of alkaline waters, such as Vichy and Karlsbad.
These waters are taken, of course, after meals. The general
tone of the stomach is, at the same time, invigorated by the
use of bitter tonics before meals. Later on in the course of
the disease, iron is used in combination with strychnia. In
some cases corrosive sublimate has been found to exert a most
beneficial influence upon the gastric and cerebral phenomena.
The hypodermic injection of dialyzed iron has been tried,
but the results have not been invariably good, owing to the
unreliability of the solution. The ammonio-citrate of iron
has proved more reliable, and five grains of it in fifteen min-
ims of distilled water, have been injected under the skin of
patients with excellent results.
ADDISON'S DISEASE.
Rest is regarded by Dr. Pepper as the chief indication, and
with it good hygienic influences and wholesome food. In
some cases an exclusive milk diet has been found to do great
good. The bowels and kidneys are carefully regulated. No
long journeys are allowed. The system is sustained upon
arsenic, iron, and cod-liver oil. Counter-irritation over the
seat of the disease is useful in early stages, as is also faridiza-
tiou with mild currents. Nitrate of silver and iodide of
potassium are administered upon general principles. The
former drug has been found to be of great use where there is
irritability of the stomach and intestines. Where the vomiting
is violent and otherwise uncontrollable, chlorodyne is used.
Where there is palpitation and dyspnoea, digitalis lias been
42 Notes of Hospital Practice.
found to be invaluable. The forms of iron usually employed
are the iodide and sesquichloride. A prescription frequently
used is the following, recommended by Greenhow :
R Ferri susquichlo.
Chloroform! aa tt\, xv-xi.
Glycerins f^j. M.
Sio. Three times a day, in water.
Not much confidence is placed in phosphorus. Alcohol is
given in small quantities and in whatever form it is best as-
similated by the stomach. Strychnia has done good in some
cases.
CHRONIC PSORIASIS.
Dr. DaCosta uses an ointment of chrysophanic acid with
the strength of one drachm of the acid to an ounce of simple
cerate. This ointment is well rubbed into the skin of the
whole body every evening. After this treatment has been
persevered in for four days, the skin becomes much paler
and smoother, and the scales begin to disappear.
PERITYPHLITIS.
In the treatment of this condition, the main indications art'
rest, alteratives and counter-irritation, in the shape of blisters
over the site of pain, and induration. In some cases ice bags-
are of service as local applications. The bowels are kept
open by mild laxatives. Indian hemp and bromide of potas-
sium are often of service. The following drugs have been
found to form an excellent laxative pill to be taken at bed-
time :
R Aloes gr. j.
Ex. cannabis ind gr.J-.
Pulv. ferri sulph gr. j. M.
Et in pil. No. j. Divide.
If there is much hardening of the surrounding tissues a
protracted course of the chloride of mercury and iodide of
General Diseases. 43
potassium in minute doses is prescribed by Dr. Pepper. In
this condition pregnancy must be avoided.
CONSTRICTION OF THE AORTA WITH HYPERTROPHY OP
THE HEART.
J. S., set. nineteen, single, was admitted into the hospital on
February 10th, 1879, and placed in Dr. James Hutchinson's
ward. The patient's history shows that his mother had died
of inflammation of the lungs, that his father is still alive, but
suffers from heart disease, and that his brother and sister are
in good health. In early life he appears to have been free
from disease of all kinds, and positively states that he has
never had rheumatism or venereal disease. His habits have
always been temperate. About a year ago he had intermittent
fever, while living near the Delaware, at Port Richmond,
which was quotidian in type, and lasted, at intervals, through-
out the winter. During the following spring and summer he
seems to have been in his ordinary health, but in the fall
caught a severe cold, which was accompanied by pain in the
chest and small of the back, cough, bloody expectoration, and
frequent micturition, which kept him in bed for two months.
While convalescing from the acute symptoms of this attack,
he suffered from dyspnoea, and noticed that his abdomen was
beginning to enlarge. There has been no oedema of the lower
extremities or of the face.
When admitted he was still suffering from cough, which
was unaccompanied by expectoration of blood. The patient
is anasmic, but not emaciated, and is rattier small and unde-
veloped for his age. His appetite is good ; his tongue moist
and but slightly coated ; his bowels are constipated and his
Lands somewhat cyanotic. He suffers from constant dyspnoea.
His urine is passed in small quantity ; it is of a clear amber
color, and contains a slight amount of albumen (1/ 12 of bulk,)
but no tube casts. Its specific gravity is 1025, and its reac-
tion acid.
44 Notes of Hospital Practice.
The impulse of the heart is felt in the sixth interspnee
external to the line of the nipple, and is heaving. Percus-
sion shows that the organ is enlarged in every direction. At
the apex a loud, blowing murmur is heard. At the base a
systolic murmur is also heard r both to the right and left of the
sternum, but less distinctly than at the point of impulse. These
symptoms and signs must have been present for at least
twelve months, as lie states that he applied and was rejected
by the medical examiner of the school ship about a year ago,
on account of heart disease. There is a small amount of liquid
'in the peritoneal cavity, and the superficial veins upon the
right side of the abdomen are very much enlarged, indicating
probably some interference with the portal circulation.
Feb. 15A. The effusion in the abdomen is increasing. The
liver can now be plainly felt, extending three fingers' breadth
below the arch of the ribs in the mammary line and also in
the mid-sternal line. Its surface is smooth and free from
nodules. The amount of urine passed in twenty-four hours
is less than a pint. The patient has been taking since his
admission Basham's mixture and broom tea, which have not
yet, however, produced any increase in the flow of urine.
March Wth. The patient has been steadily getting worse
since date of last note. He constantly expectorates blood, and
his dyspnoea is distressing to witness. All attempts to in-
crease the urinary secretion have failed, although several dif-
ferent diuretics have been given. On the other hand, the
abdominal effusion has been steadily increasing, until now his
abdomen measures 38J inches in circumference. With a view
of diminishing the effusion he was ordered to have gr. of
elaterium.
March 16th. Notwithstanding the free purgation which
was induced by elaterium, the effusion has increased to such
an extent, and the dyspnoea is so distressing, that it was thought
necessary to resort to tapping, when 10J pints of liquid were
removed. The patient bore the operation perfectly well. A
day or two ago a teaspoonful of the fluid extract of jaborandi
General Diseases. 46
was given, but the depression which followed the sweating
induced by it was so extreme that it was thought not wise to
repeat the dose.
March 17th. Patient died this morning at 7 o'clock. He
reacted fairly after the operation and passed a comfortable
day, but in the night was restless, and died in the morning
apparently from syncope.
March 18th. Atdopsy twenty -seven and a half hours after
death ; chest and abdomen only opened. The lungs were
found congested, especially the base of right lung. Through-
out the left lung were numerous infarctions ; the heart was
very much enlarged, weighing when emptied of the fluid
blood and clots which it contained, 24 oz. Its walls were
in a relaxed condition, but were very much hypertrophied.
All the cavities were dilated, especially the left ventricle.
The mitral orifice readily permitted the passage of the four
fingers of the hand, thus showing a marked insufficiency of
the valve. The aortic semilunar valves were healthy, but
just above the point of origin of the coronary artery, which
was enormously enlarged, the aorta was constricted, the strict-
ure only allowing the point of the little finger to pass through
it. Beyond the stricture the aorta was small, being little
more than half the usual diameter; the ductus arteriosus was
closed. The liver weighed three pounds. Its projection be-
yond the arch of the ribs was not so marked as during life.
External to the mammary line it was covered by them, but
within the two mammary lines it extended fully two inches
btlow them. Its substance was firm and congested. The
gall bladder contained about half an ounce of thick, viscid bile.
In the fissures of the liver were found some enlarged glands,
two of which were situated so as to compress the portal vein
at its point of entrance into the organ. There was thicken-
ing and oedema of the cellular tissue in the neighborhood, but
no traces of previous inflammation. The spleen was not en-
larged, but was deeply congested ; the kidneys were also con-
gested, but were otherwise apparently healthy.
46 Notes of Hospital Practice.
THERMIC FEVER.
Dr. H. C. Wood advises that the patient should be imme-
diately placed in an ice-water bath, and should be kept in the
water just long enough to reduce the temperature, as taken in
the mouth or rectum, to 100, and no longer. After removal
from the bath a hypodermic injection of qninia is given, to
prevent another rise of temperature.
The headache, slight elevation of temperature, general dis-
tress and mental hebetude, which sometimes accompany con-
valescence from thermic fever, are generally found to yield to
free blistering of the back of the head and neck, aided by
small and repeated doses of mercury.
ACUTE TONSILLITIS.
Dr. Pepper's abortive treatment is by counter-irritation by
iodine over the sub-maxillary region, and astringent washes to
the tonsils, such as dilute Monsel's solution, or strong nitrate
of silver (gr. Ix. to f I j,) solution. Guaiacum, in the shape of
a three-grain lonzenge, is given every three hours. In folli-
cular tonsillitis, guaiacum has been found to effect a cure in
the course of forty-eight hours in every case. The following
prescription has been found to be of great service :
R Quinise sulph gr. ij.
Tine, ferri chlor Tt^ xv.
Potassii chlor gr. v. M
SIQ. To be given every three hours, dissolved in syrup and water.
Tho, patient is in all cases put to rest in bed and maintained
oil liquid diet. If the enlargement of the gland is very great
it is lanced at once, provided pus has formed. As soon as the
suppuration ceases, astringent poultices are applied to th
neck.
General Diseases. 47
COLLAPSE.
The hot bath is employed to restore caloric, and moderate
doses of whiskey and ammonia are given internally. At the
same time, from ten to fifteen minims of the tincture of digi-
talis are administered hypodermically, in order to restore car-
diac action.
Rubbings with warm cloths dipped in the tincture of cap-
sicum, followed by the application of dry heat and wrappings
in blankets, in some cases replace the hot bath, but have not
been found to be as efficient. Dr. Wood.
ACUTE ANGINA.
Salicylic acid has acted most admirably in a case of very
severe acute angina, attended with a great rise in temperature,
Ten-grain doses of the acid, given at intervals of two or three
hours, reduced the patient's temperature from 105 to 99 in
the space of two days. This fall of temperature was perma-
nent. Dr. Pepper.
ACUTE AND CHRONIC RHEUMATISM.
Dr. Pepper continues to use salicylic acid as an antiphlo-
gistic, in these cases, with very marked success. The dose
in cases of acute rheumatism is ten grains every two or
three hours, given either in powder, or diffused in mucilage
of acacia. A very decided reduction of temperature is usually
shown in several hours. In chronic rheumatism ten-grain
doses are given thrice daily, with the like beneficial effects.
Dr. DaCosta prefers the sal icy late of sodium to tlie pure
salicylic acid.
Dr. Stille recommends in chronic rheumatism a prescription
much used in England, the so-called " Chelsea Pensioner,"
from the fact of its being first used among the rheumatic old
pensioners at the Chelsea Home.
48 Notes of Hospital Practice.
Its ingredients are as follows :
R Sulphur '..... 3ij.
Cream of tartar g j.
Powd. rhubarb 3 ij.
Guaiacum (resin) jjj.
Clarified honey ftj.
Powdered nutmeg sjij. M.
Sio. Take two large teaspoonfuls at night and morning, for three
days, in honey or mulled wine.
Dr. Pepper has great confidence in Zollikoffer's mixture :
R Pulv. resin, guiaci,
Potas. iodidi aa gr. x.
Tinct. colchici seni f^ss.
Aq. cinnam.
Syrnpi aa q. s. ad jf j. M.
Sio. A dessertspoonful to a tablespoonful, thrice daily.
ACUTE AND CHRONIC DYSENTERY.
The patient is brought to the edge of a hard bed and placed
in a position somewhat resembling that of lithotomy, his
buttocks resting upon a hard pillow in such a way as to
elevate the pelvis, and cause the injected fluid naturally to
flow downwards and inwards. The "Simon gravity injec-
tion," is then employed in the following manner : a well-
oiled, smooth, somewhat flexible, hard tube, with openings in
the sides (an cesophageal tube is what Dr. H. C. Wood usually
makes use of), and with a closed end, is gently and slowly
introduced from eight to twelve inches into the rectum. The
free, outer end of this tube is connected with a Davidson's
syringe, and the fluid to be injected thus slowly pumped in.
Sometimes the end of the oesophageal tube is united to a flex-
ible India-rubber tube, in the end of which a funnel is placed.
This funnel being then elevated some five or six feet above
the patient's rectum, the medicated water is poured into it, and
so by its own weight forces its way into the gut. Instead of
using a funnel, the tube may be so arranged as to empty a
bucket or other reservoir, which has been placed at the proper
height.
General Diseases. 49
The liquid injected is in all instances first heated to th<>
temperature of the body, and so does not provoke peristaltic
movement. The solution of nitrate of silver used by Dr.
Wood, has a strength of 3 j to the three pints of water. The
injection usually comes away in from five to ten minutes. A
solution of common salt is always at hand, and should be at
once thrown into the bowel if the nitrate of silver solution
does not come away in the course of ten minutes. The same
treatment has been also pursued with success in chronic
dysentery.
Dr. Pepper uses a solution containing only ten grains to the
quart, and introduces at first a pint and then a quart of the
solution twice daily, at first, and afterwards once in two days.
GOITRE.
Dr. Roland Curtin's successful mode of treatment has con-
sisted in the hypodermic injection of from six to ten minims
of a solution containing ninety-six grains of ergotina to the
ounce of distilled water. The injection is repeated two or
three times a week for the space of from four to six months,
when the gland becomes thoroughly hardened. The gland
begins to shrivel with the stoppage of the injections, and very
soon returns to its normal size. Ergotina has been proved to
be of no value in bronchocele, but only in cases of simple
enlargement of the thyroid gland. The injection is attended
with but very little pain, which pain is generally local, or
referable to the origin of the steruo-cleido-mastoid muscle.
DYSPEPSIA.
Among drugs, arsenic in small doses, gradually increased,
has been found to be a remedy of extreme importance.
Where there is torpor of digestion joined with very marked
sympathetic nervous disturbances, Dr. Pepper uses the follow-
ing formulae*
50 Notes of Hospital Practice.
1. R Sodse bicarb ........................ . ........................ ijiij.
Aid hydrocyan, dil ......................................... gtt. xlviij.
Tinct. valerian! .............................................. f^ j.
Syrup zingiberis ............................................. f3j ij. M
SiG. A teaspoonful thrice daily, in water.
2. R Quinise sulph ................ . ................................. gr. xvi.
Strychniae sulph ............................................... gr. J.
Acid, rauriat. dil ............................................ f.^jss-
Syrup, zingiberis ................................... q. s. ad f ^ iv. H.
SIG. Two teaspoonfuls in water, right after meals.
Where there is marked hepatic disturbance, the following
prescriptions are excellent :
S R Acid, muriat. dil ............... ................................... f^ss.
Tine. nuc. vom ...................................................... f^ss.
Infu. gentianse corap ................................... q. s. ad f J iv. M.
SIG. A teaspoonful in water after meals.
4. R Bismuth, subnit
J'epsime... ............................................................ o j- s s-
Strychnise sulph ................................................... gr. j.
Tinct. cardamon. comp ................................. q. s. ad fjiv. M.
SIG. A teaspoonful thrice daily, in water. If there is much flatulence,
an increase is made in the quantity of bi&muth and pepsin. If the case be
merely one of gastric atony, the amount of strychnia is increased.
Where there is marked gastralgia, two to five drops of
Fowler's solution are administered during the paroxysms.
If this does not control the pain, a blister two inches square
is applied to the epigastrium, and followed by a belladonna
plaster six inches square.
Where the stomach is weak, its muscular action impaired,
and its nerves over-sensitive, but little food should be taken
into it at a time. The best diet is skimmed milk, half a pint
every four hours. When milk is not well digested, lime-water
is combined with it. Such foods as coffee, tea, and tobacco
must, of course, be given up absolutely and at once. A
sovereign article of diet is buttermilk. In buttermilk the
casein of milk is coagulated and broken up, so that the stom-
ach is spared two steps of the .regular process of digestion.
General Diseases. 51
Another excellent preparation of milk is kourayss. It eon-
tains a good deal of carbonic acid. In all cases the stomach's
work is made easier by a diet consisting of eggs, milk,
starchy vegetables, stewed fruits, and a little butter, with stale
bread.
DIABETES INSIPIDUS.
Dr. DaCosta puts the patient upon an initial dose of half a
drachm of the fluid extract of ergot, thrice daily. This dose
is gradually increased, first to 1 and then to 2 drachms.
There is almost immediately a great reduction in the quantity
of urine passed daily from ten to three pints.
ULCER OP THE STOMACH,
Nitrate of silver, in the form of pills, is given in full doses
half an hour before meals. If there is pain, opium, hydro-
cyanic acid, and chloroform are administered. An exclusive
milk diet is the best. All solid foods are avoided. At the
time of the hemorrhage, Dr. Pepper insists upon absolute rest.
Pieces of cracked ice are swallowed by the patient. Monsel'a
solution, tannic, or gallic acid, are given internally. Morphia
and ergotina are administered hypodermically, and all food
for the time being (during the continuance of the hemorrhage)
given by enemata.
POST-NASAL CATARRH.
Dr. J. Solis Cohen considers cleansing to be the principal
factor in the treatment. The fluid which he employs for tliis
purpose is tepid water at about blood heat, brought up to the
specific gravity of blood, by means of some saline such as
the chloride or carbonate of sodium. The cleansing operation
is persevered in until all the accumulations are removed. To
cleanse the passages, the patient dips his nose into the vessel
containing the saline liquid, and sniffs it up into the pharynx,
52 Nates of Hospital Practice.
discharging it by the mouth; or the rubber-ball syringe, with
a long curved nozzle, 'is used. Sometimes Thudicum's nasal
douche is employed.
Another method of local treatment is by short flexible
bougies, composed of gelatine impregnated with, for example,
2 grains of sulphate of zinc, and grain of carbolic acid. A
string runs through the bougie and extends some distance be-
yond it. This is for the purpose of securing the bougie so
that it shall not drop into the throat. The bougie being in-
serted, the projecting portion of the string is fastened round
the ear. The bougie generally melts in from twenty to thirty
minutes.
LUMBAGO.
Dr. Pepper applies manipulation to the lumbar region of
the spine, so as to restore mobility. To subdue the painful
condition of the muscle, injections of !/80 of a grain of atropia
and ^ of a grain of morphia, well diluted, are made well into
the body of the muscle. Great care is had in the administra-
tion of morphia and atropia to nursing women, as belladonna
is the most powerful anti-galactagogue known, and as toa
large doses of morphia not infrequently affect the child
through its milk. The local application of blisters, iodine,
and croton oil, together with the internal administration of
iodide of potassium, are often serviceable.
LARYNGEAL PHTHISIS.
After enjoining absolute silence, Dr. Cohen applies the fol-
lowing solution to the affected parts by inhalation, or by the
brush, douche, or spray, viz. :
R Acid. carb. concent fj
Tinct. iod. comp ,"ij.
Aquae q.s. ad f^ iij M.
Sio. One teaspoonful, applied three or four times daily in an ounce of
rater, by douche or spray, or thrown in boiling water, and the vapor in-
General Diseases. 53
haled. The advantages of the spray are, twofold (1,) the water cleanses,
and (2,) its impact upon the parts stimulates. The iodine acts as an ab-
sorbent, and the carbolic acid as a disinfectant and as an astringent.
When ulceration begins, more powerful applications are
employed. Here the spray is still useful, for the part is
cleansed at all times before any local application is made.
Caution is needed, however, in making use of the spray, that
no irritating substance is employed. The inclination of an
ulcerating surface is not to heal ; and an irritant, of course,
throws a further obstacle in the way of healing. Where there
are irregular excrescences on the vocal cords or other parts of
the larynx, due to exuberant granulation following ulceration,
they are, as a general rule, allowed to remain, unless they
have grown to such a size as to interfere with respiration. If
the arytenoid cartilage becomes ulcerated, the demand is for a
soothing application, such as a weak solution of aconite and
glycerine, or a weak solution of morphia and belladonna.
The chloride of zinc, in the form of a weak solution, is an
excellent application. The action of this remedy is limited to
the points of ulceration. That astringent substance is always
employed which does the least damage to the tissues surround-
ing the ulcers. The chloride of zinc is employed in a solu-
tion of one part to fifty, or even one hundred.
In the later stages of laryngeal phthisis the nitrate of silver
does good ; but it is used without the expectation of its curing.
This substance forms a coating of coagulated albumen over
the ulcerated tissue, and so protects it from the air and from
the irritation of food. The solution of the nitrate of silver
used has a strength of from forty to sixty grains to the ounce.
It is applied merely to the ulcers at the margin of the larynx,
and not to those in its interior, which it cannot benefit. Where
the swelling of the parts interferes with respiration, and suffo-
cation is threatened, tracheotomy may be necessary for the
prolongation of life.
For the oedema Dr. Pepper uses sulphate of zinc, or cop-
per, or alum. The following is an excellent gargle:
54 Notes of Hospital Practice.
R Tinct. benzoicicomp ,
Glycerine f.^ss
Aquae q. s. ad f iv. M.
SIG. To be used as a gargle.
Inhalations of steam, of vapor of hops, or of conium, are
employed as palliatives. Counter-irritation is applied exter-
nally to the larynx, in the shape of small blisters. To relieve
the sense of fullness, lozenges of krameria, hsematoxylon, or
tannic acid are prescribed.
THE OPIUM HABIT.
Rest is the first item of the cure. The patient is kept in
bed. Ample nourishment is given. If there is a morbid
irritation of the mucus membrane of the stomach, the patient
is placed upon an absolute diet of skimmed milk, beginning
with a pint and running up to two quarts daily. All this
time the quantity of opium taken is progressively diminished.
If the conjoined milk and opium produce constipation, the
condition is overcome by massage. The abdominal muscles
are well kneaded daily. Regular injections of cod-liver oil
are given in the morning,, followed by cold water injections at
night. Iron is administered in large and gradually-increasing
doses. I>ialyzed iron is the form of chalybeate generally
employed. It is given in doses of from 10 drops to 1 fluid
drachm thrice daily, h'. Wm. Pepper.
ANEURISM.
Dr. James Hutchinson has seen considerable benefit derived
from the administration of very large doses of the iodide of
potassium. In one case lately under his charge as much as
60 grains of this drug was taken thrice daily without produc-
ing iodism, and with the effect of quite markedly diminishing
the size of the aneurism.
Another patient under the charge of Dr. Levis was put
upon the iodide of potassium in gradually-increasing doses,
General Diseases. 55
oeginning with 5 grains three times a day, and gradually
increasing the dose until he finally took 3 drachms morning,
noon and night, without producing iodism. He was also
given aconite, as an adjuvant to the iodide of potassium, in
much the same manner ; beginning with 1 drop of the tinct-
ure of the root, and gradually increasing the amount to 5
drops three times a day. His diet, too, was regulated, and
his manner of living changed. His diet was fair, as regards
quantity, but was made up of substances which do not tend to
fatten. Its composition consisted mainly of albuminous or
nitrogenized articles of diet, with a careful avoidance of all
kinds of stimulants. He lived as quietly as possible, lay down
a great deal during the day, and kept himself free from any
excitement. Rest is considered a very important element in
the treatment of this class of cases.
Under this plan of treatment the man's condition improved
very much. He has been slowly increasing in strength ; there
has been a marked improvement in his general health, and
apparently the aneurismal sac is being gradually occluded.
In other words, the aneurism is being cured by a consolidation
of the sac.
Some time since, in the case of an aneurismal sac bulging
from the subclavian artery, Dr. Levis carried pieces of horse
hair through the walls of the sac, and so succeeded in produc-
ing partial coagulation of the blood.
INFLUENZA.
Dr. DaCosta's treatment is pre-eminently a supporting
and expectant treatment, meeting special indications as they
arise, and treating symptoms mainly. Good food (systemati-
cally given) and quinia are generally considered by him as of
primary importance. Dover's powders or other diaphoretics
are occasionally used. A certain amount of wine or milk-
punch has been found to be indispensable, particularly in
elderly patients. The amount of stimulus is proportioned
to the severity of the attack.
56 Notes of Hospital Practice.
ACUTE AND CHRONIC TUBAL NEPHRITIS.
The dropsy consequent upon this disease is treated by Dr.
DaCosta with Basham's mixture and TT^xx of the fluid ex-
tract of jaborandi, three times a day. When the secretions of
the skin and kidneys are fully re-established, the jaborandi is
discontinued, and f3ss of the fluid extract of ergot is given
thrice daily in its place, the Basham being continued with
the ergot. At the same time the region of the patient's kid-
neys is rubbed with croton oil. Exposure to cold and wet
it avoided. Diet consists of milk and eggs and nourishing
broths, with very little meat. Digitalis, belladonna and iron
are often of service.
UR-EMIA,
as a result of disease of the kidneys, is treated with the fol-
lowing prescription :
R Acid benzoici gr. xz.
Syrupi tolutani fgj. M.
SIG. To be given every third hour, largely diluted with water.
Eenzoic acid has been found by Dr, DaCosta to prevent
particularly the accumulation of the urinary salts in the blood.
In addition to this treatment the patient is thoroughly purged
with croton oil. He is also given a warm bath, or, if he is
too weak, a vapor bath is taken in bed, by means of hot bricks
wrapped in damp towels. In some cases dry cupping over
the loins does good.
CHRONIC INTERSTITIAL NEPHRITIS.
Dr. DaCof ta uses this formula :
R Tinct. ferri chloridi n\,x.
Syrupi limonis Ti\,l.
Aquae
SIQ. To be taken thrice daily in a wineglassful of water.
A little wine is allowed and a nourishing diet given.
SURGICAL AND VENEREAL DISEASES.
FORIGN BODY IN THE URETHRA.
" On the 17th of July, 1878, T. D., set. 63, was admitted
into the University Hospital, for the purpose of having a
fragment of a glass tube extracted from his urethra. D. gave
the following history of his case : Has always been strictly
temperate in his habits, and has never had any affection of
his genito-urinary apparatus.
For several years patient has been one of a relief committee
of a lodge of " Knights of Pythias/' and while performing
the duties of this position he met several members of this
order who had great difficulty in passing urine, in consequence
of enlargement of the prostate gland, and were dependent
on the use of a catheter for relief. Fearing that he might
have the same trouble at some future time, and being anxious
to provide against such a disagreeable contingency, T. D.
determined to practice catheterization on himself with a glass
tube. In his first attempt he succeeded in passing a medium-
sized glass tube into his bladder, and drew off urine, without
the parts involved sustaining any injury. The success of this
experiment encouraged him to try the operation a second
time, the results of which were less satisfactory, as the sequel
will show. On the day of T. D.'s admission into the hos-
pital, he procured a straight glass tube, about 25 centimetres
(10| inches) in length, and half a centimetre in diameter,
with which he proposed to repeat self-catheterization. He
had no difficulty in introducing the tube as far as the pros-
totic urethra, but at this portion of the urethra the tube was
suddenly arrested. D., in his efforts to overcome the obstruc-
tion used sufficient force to break the tube in two nieces, one
57
58 Notes of Hospital Practice.
of which he immediately pulled out of the urethra, but the
other, being out of his reach, was left in.
Shortly after D.'s admission to the hospital, I made an ex-
amination, and found the fragment of the glass tube fixed in
the urethra, one end in the prostatic portion, and the other
penetrating the wall of the scrotal part. The fractured end
of the fragment, D. had forced through the floor of the urethra
into the loose cellular tissue of the scrotum, by his attempts to
get the tube out. He had also tried to expel the tube by
passing his urine ; but instead of displacing it, it only served
to carry urine into the scrotum, through the cellular tissue of
which the urine was quickly diffused. From the position in
which the foreign body lay in the urethra, and the manner in
which it was held there, it was evident that it could not very
easily be extracted by any instrument, such as forceps, passed
into the urethra. Nor could it be removed through an open-
ing made in the perineum without risk of doing additional
violence to the already lacerated urethral walls. To take it
out through a perineal section would necessitate the breaking
of the fragment in two or more pieces in the urethra; the
removal of which fragments would be attended with consider-
able danger, in consequence of the sharp, angular ends which the
pieces would have. In considering the difficulties of the case
from all points, it occurred to me that, in consequence of the
fractured end of the broken tube being already in the scrotum,
the safest and most practicable plan of removing the tube
would be, either to make an opening in the integuments of
the scrotum, and extract the tube through it, or to introduce
my finger into the patient's rectum, get behind the smooth
ejnd of the tube in the prostatic urethra, if possible, and push
the sharp end forward through the scrotal walls. As soon as
the patient had been brought under the influence of ether, I
directed two assistants to support his legs in the position that
they would be held in operation of lithotomy, in order that
the scrotum and perineum might be fully exposed.
I new proceeded to introduce my right forefinger into the
Surgical and Venereal Diseases. W
patient's rectum, carried it up behiud the prostate gland, till I
could distinctly feel the smooth end of the tube through the
urethral wall ; then, having made the scrota! integument tense
near the fractured end, with the thumb and finger of my left
hand, I quickly pushed the tube forward through the scrotal
wall with my right forefinger. The small wound of the scro-
tum, made by the operation, was instantly closed by contrac-
tion of the dartos structure. As the scrotum had become in-
filtrated with urine prior to the extraction of the tube, I made
four free incisions in it, two either side of the raphe, to relieve
tension and to get rid of the urine, thereby to prevent subse-
quent sloughing. For eight days after the operation the
patient's urine was drawn off three or four times a day with a
catheter, the utmost care being used to prevent the escape of
any urine through the wound in the urethra. At the expira-
tion of this period he was permitted to pass his urine in the
natural way ; this he was able to do freely and without pain,
clearly showing that the wound of the urethra had securely
healed. Apparently, as a consequence of some injury inflicted
on one of the testicles by the end of the tube, a mild epididy-
mitis developed itself soon after the accident; this attack,
however, yielded promptly to treatment, and soon subsided.
The incised wounds of the scrotum that were made to facili-
tate the escape of urine from the cellular tissue, healed in a
short time under the effects of local applications of laudanum
and water. The patient's bowels were kept at rest for four or
five days, and some slight pain relieved by suppositories of
opium ; no subsequent medication was required.
In the progress of this case it is worthy of notice that the
patient did not have either a chill, or any symptoms of
urethral fever. On the 30th of July, D. left the hospital
quite well, with the exception of a little enlargement of one
epididyoiis. The length of the fragment that was extracted
was 10J centimetres (about 4 inches.") Dr. C. T. Hunter.
60 Notes of Hospital Ptactice.
FRACTURED PATELLA.
Dr. Thomas G. Morton has treated all the cases of fracture
of the patella which have been brought into the wards for
several years past with his improved modification of Mal-
gaigne's hooks. In every instance the treatment has been
permanently successful. Dr. Morton's first modification of
the Malgaigne hooks consisted in making the hooks longer
and straighter, but this improvement was shown to be of but
slight advantage. Dr. R. J. Levis then made a further modi-
fication of the Malgaigne pattern, by cutting it into two sepa-
rate pairs of hooks. This modification also was thrown aside
after using it once. The last and most useful modification
by Dr. Morton consists in cutting the hooks into two separate
pairs, each pair consisting of one fixed and one movable hook.
At the University Hospital fractured patellae are treated
altogether by Dr. AgneVs splint. This consists of a flat pos-
terior splint, with an eminence for the popliteal space, and
with four rollers screwing in at the sides, two above and two
below. Adhesive strips coming down on each side from
above the broken bone are fastened to the lower rollers and
screwed tight, and corresponding strips from below are
secured in like manner to the two upper rollers. The frag-
ments are thus securely brought together. The whole leg is
then bandaged. This mode of treatment has given most ex-
cellent results.
Dr. Charles Hunter has lately invented a more simple
apparatus for the treatment of these fractures, and has used it
in one case very successfully. Extension is made by adhesive
strips on each side of the leg, adherent from the groin to just
above the seat of fracture. A weight is attached to the free
ends of these strips, at the bottom of the bed. The whole
leg is then tightly bandaged with figure-of-eight turns round
the knee. This method will at once adjust itself to the ne-
cessities of country practitioners, by reason of its great sim-
plicity.
Surgical and Venereal Diseases. 61
HIP-JOINT DISEASE.
When patients cannot walk they are treated in the recumb-
ent position. Dr. Agnew believes only in that form of treat-
ment which fixes the diseased joint. He believes in allowing
such patients to walk, if they are able to do so, but he does
not believe in that kind of walking which causes either friction
or motion of the affected joint. The immobility of the limb
is secured by a splint, which may be applied either on the
outer or the posterior aspect of the leg, thigh and body. The
sound limb is raised by means of a cork-soled shoe, and, if
sufficiently old, the patient is placed upon crutches. This
plan has the advantage of fixing the diseased joint, and pre-
vents the patient from resting upon the affected limb. More-
over, it admits of exercise in the open air. This treatment
lias aborted this disease in several cases in which it was be-
gun early.
ELEPHANTIASIS ARABUM TREATED BY XERVE SECTION.
The patient was a colored man, 34 years of age, a farm
laborer, and was first admitted to the Pennsylvania Hospital,
on December 1st, 1873. He had been a slave in Virginia,
where he was born and always resided until after the war,
when he came to Philadelphia. His father was crippled by
a fall, but was otherwise in good health ; his mother was also
healthy. He and a younger brother were the only ones out
of fifteen children who suffered from enlargement of the
limbs. He had never been in Barbadoes. Fourteen years
before coming into the hospital he noticed the first symptoms
of increasing size of the right leg. At first he had some pain,
especially at night, but of late years he had been able to work
as well as any one, and only felt inconvenience from the
weight of the limb, and from a serous oozing that issued from
some abrasions and kept his foot cold and wet. His general
<J2 Nolcs of Hospital Practice.
liealth was excellent, tlie disease -being mainly confined to (lie
right inferior extremity, which was markedly ichthyotic from
the middle of the thigh down to the instep. The skin and
superficial cellular tissue were veiy much hypertrophied, and
hung in large folds over the ankle-joint. Under some por-
tions of the thick, scaly epidermis there were effusions of pus.
The left leg above the ankle was slightly enlarged, but the
surface seemed natural. The skin of the abdomen showed
impairment of nutrition and alteration of structure, which the
patient said was the result of a scald received when he was
young.
Dr. Thomas G. Morton tied the femoral artery,at the usual
place, on December 12th. The temperature of the limb, taken
on the eighth day after the operation, was 98 between the
toes, and 101J on the surface of the calf, (the thermometer
being held in position for one hour.) The axillary temper-
ature was 99. The limb was enveloped in a poultice of flax-
seed, in order to remove the old epidermis. The ligature came
away on the twenty-first day, and the small wound remaining
speedily closed. The limb was then enveloped in a rollei
bandage firmly applied. This bandage was exchanged on
January 7th, 1874, for one of India rubber, which was, how-
ever, removed at the end of four hours, on account of its
producing numbness. The compression was, nevertheless,
resumed as a regular part of the treatment, and the limb
gradually and steadily decreased in size. The patient was dis-
charged on March 21st, very much benefitted. [There was
a marked improvement after the separation of the ligament,
but, as firm compression was steadily maintained with the
limb in a horizontal position, it was difficult to know ho\v
much of the improvement was really due to the operation.]
The patient was subsequently admitted into the Philadelphia
Hospital and, by the kindness of Dr. John H. Brinton, Dr.
Morton had another opportunity of examining him. The
limb was found to be nearly as large as it was prior to the
ligation; the patient, however, considered himself much im-
Surgical and Venereal Diseases. 63
proved, and thought that the operation had markedly arrested
the progress of the disease.
The man was re-admitted to the Pennsylvania Hospital, on
November 9th, 1877. The right leg was found to be double
its size when last seen, measuring twenty-one inches in circum-
ference. From the exceedingly cumbrous character of the
limb, the man desired to have an amputation performed.
Having noticed the frequency with which operations for nerve
section are followed by atrophy of the parts supplied by the
nerve which is cut, Dr. Morton determined to attempt the
artificial production of atrophy of the right lower extremity
by section of the motor nerve of that limb. Accordingly,
on November 17th, 1877, the right sciatic nerve was laid bare,
and one and one-half inches of its length exsected at the upper
third of the thigh. No unpleasant symptoms occurred after
the operation incident to the section. There has been a steady
diminution in the size of the limb ever since. On January
3d, 1878, the limb was measured, and found to be but twelve
and one-half inches in circumference, a reduction of some eight
and one-half inches from the last measurement.
An interesting feature of the case has been the desquamation
of all the thick skin which covered the limb from the kueo
to the ankle and foot, especially about the lower third of the
leg; patches of the skin, one-sixteenth of an inch thick, have
peeled off from time to time, leaving a perfectly clear, soft,
and pliable skin beneath. There has not been the least dis-
position on the part of the skin to ulcerate, and the lost sensi-
bility is confined to the extreme anterior portion of the dor-
sum, all the sole of the foot, and a strip of the integument
running directly up the posterior part of the leg to about the
middle point between the heel and the popliteal space. This
strip is about two inches in width on all portions of the leg,
except this anaesthetic strip ; the patient is able to distinguish
l>etween the compass points, provided they are held at not less
than one inch apart. Later still the reduction to the size of
64 Notes of Hospital Practice.
the limb lias become still more marked, so that when last seen
the limb was almost reduced to its normal size.
GLEET.
" Where the system is very greatly run down, it is well to
put the patient upon some such preparation as the citrate of
iron and quinine in 10-grain doses, or 20 drops of the tinct-
ure of the chloride of iron, two or three times a day, with 2
grains of quinine. If, on the other hand, the patient is ple-
thoric, he should be given some saline and an antimonial
mixture. In treating local symptoms, it is useless to give the
patient a syringe, and let him use it himself, for the injection
employed must be applied directly to the diseased spots, if
any benefit is to be derived from it, and no one can so apply
it but the educated surgeon. Moreover, such a kind of ap-
plication should be made with a special form of instrument,
so that it may reach the diseased surface, and it only. There
are a vast number of syringes, etc., which have been designed
for tli is purpose. Some years ago I was accustomed to apply
stramonium ointment and the nitrate of silver directly to the
parts by means of one or other of these inventions. The ap-
plication would, of course, cause some local irritation. The
patient would be dieted and sent to bed, and some demulcent
drink, such as flaxseed or slippery-elm tea, be administered.
In other cases, again, I used the bulbed syringe, in which,
after just passing the site of the stricture, the stream is pro-
jected backward. I have very often medicated strictures, by
means of this instrument, with a strong solution of nitrate of
silver, or with a mixture of cerate of opium and Goulard's
extract. Of late months I have undergone a change of opin-
ion in the matter of the treatment of gleet. I now think
that there is nothing in the world so good as the introduction
of nickel-plated conical bougies and the simple overstretching
of the inflamed parts." Dr. 8. W. Gross.
Surgical and Venereal Diseases. 65
CURVATURE OF THE SPINE.
In the suspension of a child for curvature of the spine,
instead of using the head-sling, Dr. H. W. Wharton attaches
a cord to the centre of the crosses over the top of the head of
Barton's bandage. This simplifies the apparatus, and is less
terrifying to the child.
ULCERS.
Dr. Charles Hunter uses the ozide of zinc as a protective in
ulcers. This compound is smeared around the edges of au
ulcer 'before applying the adhesive strips, and so prevents
excoriation of the skin.
FRACTURED CLAVICLE.
Dr. D. Hayes Agnew treats fractured clavicle by perfect
rest on the back iti bed, with the head slightly elevated. But
as the patient soon becomes restless, and as it is impossible to
secure perfect quiet after the third day unless a nurse be
secured to arrest every motion of the patient both by day and
light, at the end of that time and when the ends of bone have,
as it were, lost their disposition to get out of place, the patient
is raised carefully from the prone into a sitting posture, and
put in restraint by the introduction of an axillary pad four
inches wide and five inches long, and tapering rapidly to a
point, which elevates the arm and supports the shoulder,
while a long strip of adhesive plaster, three and a half inches
wide (Sayre's dressing), is passed round the body with a loop
to support and elevate the arm.
SURGICAL SHOCK
is treated by Dr. Agnew by the hypodermic, injection of
carbonate of ammonium mixed with brandy.
66 Notes of Hospital Practice.
CYSTITIS IN THE MALE.
If there is acute pain and spasm, blood is taken from the
perinseum by means of leeches. The patient is kept in bed,
and hot fomentations are applied over the pubes. At the
same time he takes demulcent drinks with a little hyoscyamus.
If the pain be violent, morphia is given by the mouth or
rectum.
The following prescription is frequently employed :
R Pulv. opii gr. xij.
Camphorse gr. xxx.
Ext. belladonna gr. iij.
Cacao q. s.
M. et in suppos. No. vi. ; divide.
Sio. One each night before retiring.
The diet employed is bland and unstimulating.
After the acute symptoms have abated, balsam of copaiva
is given thrice daily in capsule, or rubbed up in an emulsion.
To this, opium is occasionally added to prevent flatulence and
griping. Turpentine in capsule is used with advantage in
some cases. Other remedies are sometimes employed such
as buchu, decoction of trailing arbutus, or uva ursi with hops,
highly recommended by Sir Henry Thompson uvse ursi,
f 3 iss. ; lupulina?, 3 i; aquae, Oij. This mixture is allowed to
simmer for two hours; then enough water is poured in to
bring the quantity of the mixture up to 2 quarts, and then 2
grains of morphia and 2 drachms of the bicarbonate of sodium
are added. The dose of this mixture is a wineglassful.
In some cases benzoic acid has been found very useful.
The initial dose is 5 grains, and the quantity is then gradually
pushed up to 30 grains, and, in some instances, as much as
1 drachm is taken thrice daily.
A prescription very often employed by Dr. S. W. Grose
and other members of the hospital staff is the following:
Surgical and Venereal Diseases. 67
R Copaiba? balsami .~ iv.
Acid, benzoici 9 iv.
Gummi arabaci
Sacchari, aa ^ij.
Gaultherise olei gtt. xx.
Aquae camphorae, q. s. ad f^viij. M.
SIG. A tablespoonful every four hours.
As regards the treatment of the urine, the first thing that is
done after dilating the stricture, if one exists, is to wash out
the bladder. This is usually done in the following manner :
A gum-elastic bag, holding about 4 ounces, is procured, and
a basinful of water at 98 is made ready. Then, after draw-
ing the urine with a flexible catheter, whose end is smooth,
the bladder is washed out by simply connecting the mouth of
the bag with the catheter, which has been allowed to remain
in situ. The warm water thus injected is retained as long as
possible, then drawn off, and the operation repeated.
If the urine is foetid, 1 grain of the permanganate of potas-
sium or a small part of carbolic acid is added to each part of
warm water. When the water comes out clear, if it is de-
sired to make an impression upon the mucous membrane of
the bladder, a solution of borax (15 grains to the fluid ounce
of water) is injected, At other times a 20-grain solution of
the nitrate of silver is employed. If this solution does not
cause too much smarting it is allowed to remain 10 seconds
in the bladder.
The patient is kept at rest in bed during this treatment,
and placed upon a very bland diet. (If there be any pain
after the warm-water injections have come away, a little
morphia is thrown into the bladder and allowed to remain
there ; or, if this does not afford relief, a hypodermic injection
is given.)
In some bad cases it is necessary to perform cystotomy, or
colotomy, in order to bring about a free discharge of fluid
from the bladder.
Patients with cystitis are warned not to ride in wagons
over rough stones; if possible, to refrain altogether from
68 Notes of Hospital Practice.
riding. They are advised to avoid all stimulating drinks,
and to always wear flannel next their skin. They are no<
allowed to eat any greasy food, but are allowed plenty of fish
and oysters. Their bowels are kept open by cold-water injec-
tions, or saline cathartics.
PEOSTATOKRHCEA WITH STRICTURE.
Where the stricture is fibrous, it is gradually dilated by
means of Dr. S. W. Gross' expanding bougie. Where it is
spasmodic and due to hypersesthesia of the urethra, it is treated
by the persevering introduction of conical steel bougies of
gradually increasing sizes. If the nieatus is unusually small
it is slit up.
In obstinate cases of this nature astringent local applica-
tions are necessary, such as nitrate of silver, which is applied
by means of the porte caustique devised by Prof. S. D. Gross.
The solid nitrate is the form of silver used. After applying
the caustic the patient is kept in bed, his diet reduced, and
demulcent drinks administered freely.
If there be constipation, the bowels are kept well open by
means of an occasional purge, or the patient takes as a routine
medicine, each morning before breakfast, f vi of Hunyadi
Janos water, or the following prescription, which was first
originated by the late Dr. Robley Dunglison :
R Mag. sulphat j.
Potass, bitart 3J.
Ferri sulphat gr. x.
Aquae q, s. ad Oij. M.
Sio. A wineglassful every morning before breakfast.
Another excellent plan which is often pursued is to inject
five or six gobletfuls of cold water into the rectum each
morning.
The diet provided is nutritious but bland. No coffee, tea,
malt or alcoholic liquors, and no greasy or fried foods, arc
allowed.
Surgical and Venereal Diseases. G
For breakfast he is given grits or oatmeal, meat, and bread
and butter ; for dinner, plenty of good rare beefsteak or mut-
ton-chop, with potatoes, tomatoes, etc. Supper should be a
light meal.
If there be any anaemia, something like the following ia
given :
li Quinitesulph gr. xl.
Tinct. ferri chloridi. f.^iv-
Tinct. nucis vomicse f^ivss.
Aquae q. s. ad f ^ ijss. M.
Sio. A teaspoonful four times daily in water, through a siphon.
If, on the other hand, there is a tendency to plethora, de-
pressants and purges are employed. The patient takes a sitz-
bath every night and morning. He sleeps on a hard mat-
tress, empties his bladder thoroughly before going to bed, and
uses only the lightest of coverings.
To keep down the venereal appetite, 30 grains of the bro-
mide of potassium are given thrice daily.
Where the condition is obstinate, local blistering is resorted
to. A camel's-hair brush is dipped in cantharides and col-
lodion, and a couple of lines are drawn with it, first on one
side of the raphe of the perineum, and then on the other.
Intercourse is had regularly, so that the distended seminal
vessels may be relieved, but it is never had at shorter inter-
vals than every two or three weeks.
Where there is functional disease of the heart with palpita-
tion, and flushing of the face, there is nothing better than
digitalis in small and long-continued doses. It may be given
in any of its medicinal forms.
N^VUS MATERNA.
Two oiled pins are pushed right through the base of the
growth so that they cross each other at right angles. A
groove is then cut all the way round between the points of
entrance and of exit of the pins with a sharp knife. A stout
70 Notes of Hospital Practice.
ligature is then passed round the base of the naevus and under-
neath the pins, and is drawn so tight as to completely stran-
gulate the growth. Dr. S. W. Gross does not believe in tem-
porizing in these cases by the use of the cautery or by the
injection of irritating substances into the body of the tumor.
are treated surgically by incising the pile with a bistoury, and
then pressing out its contents, viz., the contained clot of blood.
This slight operation relieves the pain and tension at once.
As an after-treatment the parts are well bathed with cold
water, and some medicine given to act on the liver and
bowels. Dr. Samuel D. Gross does not at all believe in the
immediate removal of these growths with the knife, as recom-
mended by Erichsen and Bryant.
TAPPING IN DROPSY.
Dr. J. Solis Cohen treats obstinate cases of dropsy of the
legs by tapping. The minute trocars which he uses are made
of gold, with openings at the ends and on the sides. They
have sharp three-cornered points. In inserting these canulae
they are thrust well into the flesh from below upward and
then fastened in position by strings tied to their bulbous ex-
tremities. These strings are fixed by pieces of adhesive plaster.
When the canulae are fixed in position, slips of rubber tubing
are fastened to their bulbous extremities. Where the fluid does
not flow freely after the canulse is inserted, its flow is started
by pulling the rubber tubing between the fingers pressed
tightly together, and so creating a vacuum. Care is had not
to insert the canulae too far down in the limb, where their
presence may produce a sore, owing to the weight of flesh
above them.
Surgical and Venereal Diseases. 71
THE HYPERDISTENTION OP ABSCESSES.
This treatment of abscesses, first used by Mr. Callender, of
London, has been tried with excellent effects at this hospital.
The cases were both of them in the service of Dr. H. Lenox
Hodge. In the first, that of a large femoral abscess in a
child suffering with coxalgia, the abscess was first opened with
a bistoury, and a large amount of pus discharged by gentle
pressure. A 5 per cent, solution of carbolic acid in water
was then injected through a common syringe, with tube
attached, so as to completely fill up the abscess to overflowing.
This hyperdistention caused a number of cheesy, shreddy, and
fibrous particles to be discharged. No constitutional symp-
toms followed, and no pus was to be found subsequently upon
the carbolized oil-dressing. The injection was repeated thir-
teen days later. At no time after the first injection were
more than a few drops of pus exuded.
In the second case the results, though fair, were not so im-
mediate and pronounced as in the first case ; the temperature
showing a constant tendency to rise and the pus still continu-
ing to be discharged.
RAPID RECOVERY FROM DEPRESSED FRACTURE OF THE
FRONTAL, BONE.
The following case occurred in the service of Dr. H. Lenox
Hodge : T. C., set, 4, while playing on tow-path of a canal,
was caught under his chin by the tow-line, and thrown
violently down a bank estimated to be about twelve feet high.
His head came in contact with a piece of cinder. This acci-
dent occurred at 6 P. M. on June 24th. The child was in the
hospital by 8 P. M. Upon examination, a depressed fracture
of the frontal bone about three-quarters of an inch above the
superciliary ridge upon the outer edge of the frontal eminence,
was found. The wound extended for some seven lines, and
was accompanied by much laceration of the soft parts. The
72 Notes of Hospital Practice.
pupils were widely dilated. The breathing was stertorous,
and the condition that of general hebetude. The boy was not
rendered insensible by the fall, but soon afterward lapsed into
a comatose condition, only arousing himself to ask for water.
The treatment consisted in the coaptation of the sides of
the wound with adhesive strips, and in placing over this a
dressing of simple cerate. An ice-bag was applied to the
head and a simple fever mixture given internally. The tem-
perature immediately upon admission was 99 F. The next
morning the boy was bright and cheerful ; complained of no
pain and asked for food. His pupils were contracted. As a
precaution a catheter was passed, but its use was not again
required.
June 2Qth. Bowels not yet opened. A dose of castor oil
given.
June 27th. Bowels still inactive, but boy very bright and
enters readily into conversation on any topic.
June 28th, Bowels and bladder both acting regularly.
Wound healing. Boy takes nap or two during day and sleeps
regularly at night. Patient left hospital soon afterward,
entirely well.
SERIOUS BURN FOLLOWED BY CONTRACTION OP TISSUE-
CURED BY NITRATE OF SILVER AND PRESSURE CARE-
FULLY APPLIED BY MEANS OF ROLLERS.
J. T. F., set. 10, admitted to the hospital on January 14th,
1879. This boy was badly burned, both above and bel.ow
the elbow, and completely around the arm. Before coming
to the hospital he had been treated for some six months at his
home.
When first seen by the resident surgeon, Dr. J. M. Taylor,
the burn was seen to have penetrated the muscles and showed
pouting granulations of from two to three inches in diameter,
encircling the arm. The elbow was much contracted.
Surgical and Venereal Diseases. 73
When Dr. John Ashhurst, Jr., saw the case he thought that
amputation would have to be performed. A dressing of oxide
of zinc was immediately applied, the discharge of pus at that
time being considerable. On the 20th of January, six days
after admission, the granulations had very largely diminished
under the use of the nitrate of silver, and in some places
above the elbow the skin had united, forming narrow patches
of healthy epidermis. On January 28th the granulations
were all healing rapidly. On February 16th the arm was
entirely cured.
The resident surgeon, Dr. Taylor, took great interest in the
case, and each day straightened the arm out carefully as far as
it would go, seeking to make it straighter at each visit. The
nitrate of silver was applied with great thoroughness and
care, and after each application the arm was bound up pretty
tightly with turns of the roller over an oakum pad.
8PEAIN8.
The routine treatment of sprains pursued at the Philadel-
phia Hospital, is that first introduced by the late Dr. Paul
Goddard. The injured part is placed in a bath at the tem-
perature of 70 F. The temperature of the water is then
gradually raised until the extreme point of toleration is
reached. This hot-water treatment has in every instance been
followed by the most excellent effects.
GONORRHOEA IN THE MALE.
Dr. J. H. Brinton employs carbolic acid, in the shape of a
solution containing gtt. ij of the acid to f i of lime-water,
as a local application in the acute stage of the disease. At
the same time cubebs is administered internally in doses of a
tablespoouful in half a tumblerful of water three or four
times a day. This dose is pushed until diarrhoaa or nausea
supervenes, when the quantity is reduced.
74 Notes of Hospital Practice.
STRICTUKE.
Dr. S. "W. Gross considers that the only rational treatment
of stricture consists in the restoration of the normal calibre of
the urethra at the affected portion, and that the meatus should
therefore be enlarged so as to admit of the passage of an in-
strument of the size adapted to restoring the constricted part
(whose dimensions may be ascertained by means of the ure-
thrometer devised by Dr. Gross) to its original dimensions.
Dr. Gross claims, however, that dilatation never effects a per-
manent cure, and should therefore never be employed except
in those cases where there is disease of other portions of the
urinary apparatus.
He treats stricture almost entirely at present by internal
urethrotomy, since he has determined from post-mortem ex-
aminations that there are very often sub-mucous bands which
resist the action of the divulsor.
Having determined upon internal urethrotomy, he first
allays the spasm and tenderness of the urethra by passing at
first, and at long intervals, a moderate-sized conical steel bou-
gie, gradually increasing the size of the instrument and de-
creasing the length of the intervals. If the meatus is the seat
of stricture, or is smaller than the rest of the urethra, it is cut
as a preliminary measure.
Ten grains of quinia are given before the operation, and the
patient is made to pass his water so that the wound left by
the urethrotome may have become glazed before the next act
of micturition. The rectum is always emptied before the
operation. Dr. Gross employs a urethrotome devised by him-
self, and made by Mr. G. Tiemann, of New York.
Immediately after the operation a conical steel bougie,
whose size corresponds to that of the normal urethra, is passed
and withdrawn, and of a grain of morphia is thrown under
the skin. The patient is then confined to bed for forty-eight
hours. The bougie should be introduced once every day foi
some time after the operation. Dr. Gross considers internal
urethrotomy from behind forward the most effectual oneration.
Surgical and Venereal Diseases. 75
The treatment of stricture of the urethra followed by Dr.
Briii ton is not an exclusive one In the majority of cases he
relies upon gradual dilatation, especially when (he stricture is
situated at or near the membranous portion of the urethra.
In making dilatation he uses the ordinary Thompson's sound,
and when much resistance is encountered he stretches the
stricture rapidly with Thompson's dilating blades. In stric-
tures of the spongy portion of the urethra, when, from any
cause, slow dilatation is undesirable, he practices divulsion by
Holtz's method, and also internal urethrotomy, using for the
latter purpose an ordinary Charriere's instrument. He pre-
fers urethrotoray to divulsion, particularly in irritable and
resilient strictures. Strictures at or near the meatus he di-
vides. In practicing the common process of gradual divul-
sion, when the stricture is tight and the opening small or
tortuous, he usually employs whalebones bougies and Gouley's
tunnelled catheters. The whalebone he makes himself, and
they are very much finer than those to be bought in the shops,
which, nine times out of ten, are not sufficiently flexible, and
are therefore useless. Dr. Brinton insists with great empha
sis upon the permeability of all strictures, with occasional
exceptions, i. e., those of traumatic origin. In difficult cases
the passage of the whalebone is a work demanding great dex-
terity and gentleness, and, according to this surgeon's teach-
ings, cannot be confidently anticipated if the patient has been
practiced upon the same day with instruments of larger
diameter and with rounded points. When a stricture is sus-
pected, or known to be a tight one, he invariably uses first tho
whalebone and over it the tunnelled catheter, deferring to a
later stage of dilatation, instruments flexible, or soft, of in-
creased size.
In the practice of the Philadelphia Hospital, Dr. Brinton
deprecates unnecessary interference with the urethra. The
patients in this institution are paupers, collected from the
lowest ranks of life, with constitutions utterly broken down
76* Notes of Hospital Practice.
by exposure and debauch. In his judgment the results ob-
tained from operations upon such subjects are greatly inferior
in point of success to those which attend like operations in
private practice.
SYPHILITIC SORE THKOAT.
The parts are kept thoroughly cleansed. This cleansing ia
performed with a syringe, brush or spray douche. The water
used contains some of the chlorate or permanganate of potas-
sium, or some carbolic acid. Local medication is not em-
ployed unless ulceration has set in. Occasionally a 20-grain
solution of the nitrate of silver, or sulphate of copper is.em-
ployed. In making these applications care is taken to cover
the whole patch, so that the diseased tissue shall be completely
destroyed.
Where Dr. Cohen desires to make a good local application,
instead of a camel's-hair brush, he uses a broad or flat paint
brush, so that one sweep of the brush will cover a space half
an inch wide. In this way the whole diseased surface can be
washed by one motion.
The best form of lunar caustic has been found to be that
which comes in the shape of a lead pencil. This contrivance
enables the physician to confine the cauterization strictly to
the unhealthy tissue. When an application is made to the
side of the palate, the wood is cut away from the pencil so as
to leave a small piece of the caustic exposed laterally.
The constitutional treatment of the secondaiy syphilitic
sore throat consists in mercurialization, and of the tertiary in
iodization.
When perforation is threatened, the iodide of potassium is
given in doses of from 30 to 90 grains every three or four
hours, for thirty-six hours, if necessary, or until a change for
the better takes place.
In giving large doses of the iodide, the patient's throat ia
carefully watched to see that oedemu of the larynx does not occur.
Surgical and Venereal Diseases. 77
If the patient comes in in such a late stage of perforation
that the uvula is found to be suspended from its base by only
a thin shred of flesh, Dr. Cohen's rule is to let it alone unless
it gives rise to harassing cough, when it is clipped off with a
pair of scissors. If this necessity does not occur, the strong
probability is that the separated parts will unite again so soon
as the system is thoroughly under the influence of the iodide
of potassium.
With regard to the question as to how long the system
should be kept under the influence of anti-syphilitic remedies,
Dr. Cohen's rule is that these remedies should be continued
until all evidence of the disease has ceased, and that they
should even then be kept up for a couple of months longer,
and then that small doses should be taken every few weeks,
and whenever the throat shows the slightest disposition to take
on specific inflammatory action.
TEMPORARILY IRREDUCIBLE HERNIA.
If the irreil ucibility is due to the distention of the sac by
air, or by faeces, Dr. Agnew at once proceeds to attempt to
dislodge the sac's contents. The patient is placed upon his
back, his shoulders elevated, his thighs flexed upon the ab-
domen, and gentle compression instituted over the region of
the tumor. This compression is made with great care and
very gradually. If, at the end of fifteen minutes, a little
yielding is felt and a slight gurgling sound hoard, the prog-
nosis is good. If this gentle compression is not followed by
these signs it is stopped at once and something else tried. In
the case of an inguinal hernia some leeches are placed over
the course of the spermatic cord; if femoral, they are put
above the saphenous opening, and a cold water dressing
applied.
If the case is still obstinate, the patient is kept quiet on his
back, and the following prescription given :
78 Notes of Hospital Practice.
B Pulv. opii gr. j.
Ext. belladonna gr. ss.
Ext. aloes,
Pulv. rhei aa gr. ij.
M. et in pil. No. iy. ; divide.
Sio. One pill every hour.
The cold water dressings are kept over the part. In the
course of eight hours an injection is given. In cases where
the stomach will retain anything, castor oil is given in doses
of two teaspoonfuls every two or three hours, as a cathartic.
[Dr. Chas. Hunter has performed Dr. Dowell's operation
for hernia (strangulated) in a number of cases with positive
success.]
A UNIQUE CASE OF INJURY TO THE BRAIN.
" E. A. D., set. 40, on April 27th, 1879, walked into the hos-
pital and up stairs. The top of his head was in a horrible
condition. There was a lacerated wound three inches long by
one and a half wide, and very deep. The integument had
sloughed or been torn away, the bones were missing, the dura
mater was exposed and sloughing, and the brain could be
seen pulsating in the foul mass, which it seemed to be trying
to pump out. The patient was perfectly rational, and gave
the following account of himself:
He was first officer in a three-masted schooner sailing from
the West Indies to New York with a cargo of sugar. He
had worked very hard at loading the vessel in the heat, and
for two days and nights after sailing for home he was con-
stantly on the watch. He suddenly became ill, and conceived
the idea that the captain and crew were going to murder him
and throw him overboard. To frustrate them he thought he
would take his own life, and tried to jump overboard, but was
prevented from doing so. On the fourth day out, when off
Cape Hatteras, he got possession of an axe and dealt himself
several severe blows on the top of the head with the handle,
fracturing the skull. He then, witli the sharp edge, chopped
Surgical and Venereal Diseases. 79
out the softened mass, and picked away pieces of the bones.
After this he got better and returned to normal consciousness.
On the 25th, four days after inflicting the injury, the vessel
arrived at New York. The patient walked to the cars and
came to Philadelphia. ,
He said he was a temperate man, that he only took an
occasional drink, and that he was not in delirium tremens.
His appearance certainly did not indicate a man of intemper-
ate habits. His story was so unlikely that it was of course
doubted, but no inquiry elicited iiy other statement, and he
persisted in it to the last, bringing no accusation against any
one in fact volunteering the declaration that the captain and
crew were the best he had ever sailed with.
The sloughs were partially cleared away, several small
pieces of bone were removed, cold compresses with mild anti-
septics were applied, and a nourishing diet ordered.
The patient was in the third story. I feared he might- 1
attempt to jump from the window, and so ordered him to a
private room in the basement. He remained there for one
night, but protested against it, and earnestly requested to be
sent back to his old quarters, saying that he knew perfectly
well what he was about, and that it was too much like a
prison down stairs. His request was complied with, and there
was no trouble.
By May 1st more serious symptoms set in. There was-
high fever and a quick pulse. The temperature was 1|
higher on the right side than upon the left. This side was
the seat of spasmodic twitchings and contractions, and by the
4th it became completely paralyzed. A hernia cerebri was
also beginning in the wound, and there was some stupor.
There was no facial palsy. On the 5th there was an attack
of erysipelas, from which the patient recovered in a few days.
Discharges had in the meantime been thrown off freely from
the wound, and on the 7th an interesting event occurred. Dr.
Mcllwaine, while dressing the wound, saw the end of a piece
af bone deep down in its anterior part and to the right side,
80 Notes of Hospital Practice.
about an inch in front of the coronal suture. This and
another piece he removed. These were pressing upon the
right hemispheres in this position. There was some venous
hemorrhage, and a small black clot, which was also taken
out. The pieces were respectively xj an inch and fxf of
an inch in size. They had been actually driven down and
buried under the sound part of the skull by the force of the
blows, and were only exposed by the cleaning up of the wound.
Almost immediately the paraplegia in the left arm was re-
lieved, and by the next dayfthat in the leg had also disappeared.
The stupor was gone. The patient said he felt more
rational, and he could bring his will to bear upon any de-
sired movement, although he was weak.
This relief proved, however, to be but temporary. From
day to day signs of brain x disorganization and abscess were ap-
parent. The paralysis returned, at first more manifest on the
left side, but before death it became general. The intelligence
was good up to within a few days of death, as rational an-
swers were given to questions. There was no active delirium.
There was much fever, the temperature chart showing a range
from as low as 98 J on the 19th of May up to 106 on the
31st. Control over the bladder and bowels was lost. On
the 31st of May there was entire unconsciousness, and death
took place at 2 p. M., June 1st.
Autopsy. After the scalp was removed numerous linear
chips of bone were found, and many linear scratches, twenty-
five or more, which were made with a sharp instrument, were
upon the outer faces of the frontal and parietal bones, and all
were in a parallel line with the opening in the calvaria. This
was 3 inches long and 1 inch wide. One inch in length was
taken out of the frontal bone and the rest was from the parie-
tals. There was an abscess leading from the base of the cere-
bral hernia to the corpus callosum. An abscess was in each
hemisphere. Pus was infiltrated between the cerebrum and
cerebellum. The dura mater was torn and thickened near
the posterior portion of the wound, and here also there was
Surgical and Venereal Diseases. 81
abscess. The lateral ventricles were filled with serum. At
the bottom of the longitudinal fissure there was a piece of
bone an inch long and 4 lines wido, about which there was
an abscess. Dr. Wm. Hunt"
EXTENSION IN FRACTURES BELOW THE KNEE,
Dr. S. W. Gross treats in this way : The foot is well band-
aged and covered with turns of a roller. A shingle is then
cut to fit the shape of the sole and fastened to the foot by ad-
hesive strips. The weight is attached to a knotted cord
passed through the centre of this foot-piece. Potts' fracture
is treated in this way, after first bringing the inverted foot into
its normal position by means of a broad adhesive strip run-
ning from the inside of and across the middle of the sole, well
up on the outside of the leg
FRACTURE OF THE CLAVICLE.
The arm is flexed and bound to the body. A silicate of-
sodium dressing is then applied so as to retain it in position.
A pad in the axilla is necessary in lean subjects. Dr. J. If.
Brinton.
INTRACAPSULAR FRACTURES.
Instead of extension by adhesive strips and the use of'wmtl
bags to keep the fractured limb in position, Dr. S..AV. Gross.- by
placing pillows under the knee, puts the leg into the shape of a
double inclined plane. The adhesive strips are then attached
on both sides, from the seat of the fracture to the knee, and
are carried from that point straight out to a pulley :md weight
at the foot of the bed.
COMPRESSION OF THE BRAIN.
The treatment employed by Dr. R. J. Levis consists of
rst in bed, with the head and shoulders slightly elevated, to-
#2 Notes of Hospital Practice.
getlier with stimulating injections of turpentine and water
Tui-pentine beaten up with water (for it is not soluble in it)
and thrown into the bowel with a syringe, in the form of a
mixture, lias been found to make a veiy good stimulating injec-
tion. It not only produces a stimulating effect upon the system,
bul causes what is equally desirable, a free evacuation of the
bowels. In addition to this, an active mercurial cathartic is
administered, and the patient is placed upon full doses of the
bromide of potassium, 60 grains of this drug being given in
tho course of the first twelve hours, and subsequently reducing
tho dose to about one-half. In dealing with a patient in this
condition, it is always borne in mind that if deglutition be
impaired, as is usually the case, medicines and articles of food
should not be given by the mouth, but rather by the rectum,
because if a patient cannot swallow, there is great danger that
whatever may be introduced into the mouth will pass down
into the trachea and produce strangulation. For the same
reason, if mucous accumulates in the trachea and bronchial
tubes, the patient is inverted, to facilitate its discharge.
EPITHELIAL, CANCER.
The treatment pursued by Dr. Richard J. Levis consists in
the destruction of the cancerous tissue by successive applica-
tions of chromic acid. This acid- destroys by rapid oxidation.
The pure acid is prepared for application by diluting the
crystals just enough to render them liquid, so as to permit of
icady application with the brush. It is then applied to the
margin of the cancerous growth, upon all sides, and the appli-
cation is repeated from time to time, as the case may demand.
In this way the morbid growth is gradually encroached upon.
INGROWING TOE-NAIL.
Dr. Charles T. Hunter's plan of treating this condition,
consists in introducing .a thin layer of surgical cotton beneath
Surgical and Venereal Diseases. 83
the edge and extremity of the offending nail, thereby keeping
the sharp edge of the nail separated from the ulcer, until the
latter cicatrizes. A small roll, or pledget, of cotton is placed
along the lateral margin of the nail so as to keep the promi-
nent granulations pressed away from the nail. The dressing
is kept in place by a film of collodion, and a narrow strip of
adhesive plaster wound two or three times around the toe.
Before the cotton is gently pressed, or crowded beneath the
depressed nail-margin, collodion is painted over the surface
of the ulcer, in order that the granulations may be com-
pressed by the contractile film left by the evaporation of the
ether contained in the collodion.
To introduce the cotton, Dr. Hunter uses a steel probe with
one end hammered quite thin (about J of a line in thickness,)
and slightly curved on the flat the curve corresponding to
the lateral curve of the nail. The other extremity of the
probe is likewise flattened, but not curved. The probe used
is four inches long.
ERYSIPELAS.
Dr. Samuel D. Gross finds the best local wash to consist in
a solution of the acetate of lead, ( 5 ss to Oij.) A cloth,
saturated with this solution is placed over the parts and cov-
ered with oiled silk, or waxed paper. When the digestion is
impaired calomel is administered, and followed in the course
of six hours by a dose of castor oil. Quinia and the tincture
of the chloride of iron are always administered for their tonic
effect. If there is much circulatory disturbance, gtt. ij of the
tincture of the root of aconite are given every four hours.
Great attention is paid to the ventilation and diet. In the
phlegmonous variety the best local treatment has been found
by Dr. Gross to consist in free incisions. In every instance
the patient is at once separated from the other patients, and
if it be in summer he is quartered in a tent, outside of the
main building, where there is plenty of fresh air and sunshine.
84 Notes of Hospital Practice.
PARAPHIMOSK.
In mild cases Dr. S. D. Gross finds that the swelling can
be reduced by the application of a solution of the acetate of
lead, ( 1 ss of the acetate to Oij of water,) or by mercurial
ointment. When the infiltration is great, the reduction of the
swelling is secured in the following manner : The penis i.s
grasped behind the retracted prepuce, and the blood is gradu-
ally forced out of the head of the penis, which is then pushed
back, while the prepuce is pressed forward. When reduction
is not to be accomplished by this compound movement, an
incision is at once made through the stricture formed by the
prepuce with a bistoury. In all cases where there is much
infiltration, incisions are made into the infiltrated part, in
order to allow the serum to escape. The penis, in this dis-
ease, is always so placed as to point towards the umbilicus.
THE MEDICAL AND SURGICAL DISEASES OF
WOMEN.
PELVIC PERITONITIS AND CELLULJTIS.
If the attack cannot be aborted, the treatment is taken up
regularly, the two most important indications being (1) to
stop the pain, and (2) to prevent the formation of pus. With
these ends in view full doses of opium and of the bromide of
potassium are given together with from thirty to forty grains
of quinia daily. The abdomen is painted with iodine and
covered with a poultice. If the woman is plethoric the mor-
phia is given by the mouth with neutral mixture and wine of
ipecac. In some cases tonics are demanded. Occasionally the
application of belladonna and blue ointment locally proves
beneficial.
If the attack lasts for more than a week and the local ten-
derness increases, the hot- water douche is applied to the tender
cervix uteri. It is at this stage also that flying blisters are
applied, beginning with a good-sized blister over the iliac re-
gion. In some cases this is all that is required. When the
tumor still persists, however, another blister is put on over the
womb, and then another over the other side of the abdomen,
and so on until the swelling disappears entirely.
If at any time a sudden chill supervene, the plan followed
is to begin all over again with large doses of quinia and of
morphia.
When pus has formed tonics are administered, and among
them iron especially.
In the later stages of the disease muriate of ammonia has
been found to be a very excellent remedy.
The following prescription is that usually employed :
85
86 Notes of Hospital Practice.
Jjt Mist, glycyrrhizse comp f|jvi.
Ammonii chloridi Jjij.
Hydrarg. chlo. corrosivi gr. i.
Tinct. aconiti radicis gtt. xxiv. M.
SiG. A tablespoonful in water every six hours,
If pus has formed, and it becomes impossible to secure its
absorption by medicinal means, the spot is found where the
abscess is beginning to point, and an incision made large
enough to admit of a free drain of pus. After aspiration the
cavity is injected with a solution containing one part of iodine
to nine parts of water, or, in some instances, a five per cent,
solution of carbolic acid is employed. Dr. Goodell.
ANTEFLEXION OF THE UTERUS.
The patient was a servant-girl, 27 years of age, with a his-
tory of menstrual irregularities extending through a period of
seven years. Accompanying the flow there had been occasional
suprapubic pain. Six months before her admission to the
hospital this pain had become constant, and she had been
compelled to give up all work. She was obliged to pass her
water twenty or thirty times a day. The urine was examined,
and found to be entirely normal in all respects.
Vaginal examination showed the uterus to be a little lower
than natural, the finger encountering the fundus in the ante-
rior cul-de-sac. Together with this anteflexion there was
some catarrh of the bladder, while the woman was anaemic
and hysterical, and suffered greatly from constipation.
It was concluded by Dr. J. F. Meigs that the first thing to
do was to build up the woman's general health. Rest in bed
was enjoined ; thrice a day she took gr. iv of the ammonio-
citrate of iron with gentian, and the following prescription
was employed, viz. :
R Magnesii sulphat vj.
Acid sulph. dil gij.
Ferri sulph gr. xij.
Quinise sulph gr. xij.
Syrupi zingiberis f.^j.
Aquse q. s. ad f 3 vi. M
8i(. A tablesnoonful in ice- water thrice dail v.
The Medical and Surgical Disease* nf Women. 87
To cure the anteflexion, instead of introducing a pessary it
was determined to persuade the woman to teach her bladder
to hold gradually more and more urine. It was reasoned that
when the bladder could hold twelve ounces the anteflexion
would be largely reduced.
THE VOMITING OP PREGNANCY.
A good prescription is, viz. :
R Cerii oxalat gr. i.
Ipecacuanhae gr. i.
Creasoti gtt. ij. M.
SiG. To be taken every hour. Dr. Gooddl.
This same prescription has been used with much profit at
the Episcopal Hospital.
H.EMATOMA IN DOUGLAS' POUCH.
Dr. Goodell's plan is to keep the patient perfectly quiet s^d
administer astringent drinks, such as sulphuric acid lemonale,
etc. Opium enough is given to lull the pain and keep 1 he
patient thoroughly quiet. For a number of hours following
the attack, but a very slight amount of nourishment is giv*-n.
Stimulants are refrained from, and the patient is kept as It^w
as possible, until all immediate danger from peritonitis has
passed away. If the woman is married her vagina is pack-*!
with ice, but in the case of a virgin, where the hymen s
intact, the ice is placed over the abdomen and perinseum.
PERIMETRITIS.
The first thing done by Dr. Goodell is to put the woman to
bed and keep her quiet. Flying blisters are then applied
over the abdomen. A mush poultice is put on as soon as
the blister begins to draw. The first blister is placed on the
88 Notes of Hospital Practice.
right side of the abdomen, and then, in the course of a few
days, another is applied to the left side, and then one
over the middle; l/ 2 4 of a grain of the bichloride of mercury,
with 10 grains of the muriate of ammonia, are given three
times a day in the rnixtura glycyrrhizae composita. A pessary
of cotton is constructed which can be so adjusted as to hold
the womb up. This cotton is dipped in a solution containing
of a grain of morphia to the drachm of glycerine. The
morphia allays the pain and reduces the inflammation, and
the glycerine usually sets up a copious watery discharge from
the vagina. Iron is not employed until late in the progress
of the disease.
After the inflammation is subdued, the patient is put upon
the following mixture :
R Hydrarg. chlor. corros gr. j.
Liq. chloridi arsenitis f^ 88 -
Mist, ferri chloridi.
Acid, muriat. dil aa f^ij.
Syrupi ff iij.
Aquse q. 8. ad f^vj. M.
Sio. One tablespoonful after each meal.
POST-PAETUM HEMORRHAGE.
The management of post-partum hemorrhage is divided by
Dr. R. A. F. Penrose into preventive and curative treatment.
First, as regards preventive measures. If the woman is ple-
thoric and has bled profusely at former labors, saline purga-
tives and diuretics are employed, and she is kept upon a low
diet for some time previous to confinement. If there is marked
anaemia, iron, bitters, stimulus, and plenty of good, nourish-
ing food is used. If the labor proves long and tedious, it is
hastened by the careful and skillful use of the forceps. If it
is too rapid, on the other hand, the endeavor is made to ren-
der it slower by anaesthetics, etc. As soon as the child is
born ergot is given freely, and all external means of causing
contraction are brought to bear upon the case.
The Medical and Surgicat Diseases of Women. 89
The curative treatment consists (1) in removing the placenta
at once, in administering ergot, and in placing one hand in
the cavity of the uterus and making firm pressure over the
abdomen with the other. If .these fail, (2) a cold application
is at once made. A piece of ice about the size of a walnut, is
carried right up into the cavity of the womb. If the ice does
any good, it dogs it at once. If the patient still bleeds, (3,)
a piece of rag is dipped into a cup of vinegar and then car-
ried up into the uterus and squeezed, or a lemon is pared,
gashed in numerous places, carried up into the womb and
squeezed. The (4) last alternative consists in instituting com-
pression upon the large vessels at the posterior part of the
abdominal cavity, and in administering a good dose of opium.
When the hemorrhage is checked ergot is given freely, and
a tight binding is placed over the lower part of the abdomen.
A napkin is placed below the vulva to give notice of any re-
turn of hemorrhage. The patient's head is placed low down
by removing pillow and bolster. If there is a marked dis-
position to faintness, the feet are elevated.
During convalescence the circulation is stimulated by lauda-
num, by the mouth, or morphia hypodermically. Alcohol is
given, either in water or milk. The nerves are toned up by Hoff-
mann's anodyne, or by the sweet spirits of nitre. Plenty of
saline food is given with milk. The rest of the treatment
consists in watching the patient carefully and keeping hei 1
quiet.
At the Woman's Hospital, Dr. Anna E. Broomall controls
post-parturn hemorrhage by means of the hot-water douchf..
It is thus administered : the largest size of bed-pan is placed
beneath the patient's hips. A Davidson's syringe is employed.
The water used is brought to a temperature of 110 Fahr.,
and is not less in quantity than two quarts. A higher tem-
perature is not well tolerated, and a lower temperature has
been found to be ineffective. The amount of the injection
has been given as not less than half a gallon, but the rule is
to continue the injection until the return stream is clear.
90 Notes of Hospital Practice.
Care is taken to see that the syringe is in good order, and that
(he air is thoroughly forced out of it before it is used. A
metallic tube six inches in length is employed instead of the
vaginal nozzle which comes with Davidson's syringe, and
which is apt to act as a medium for puerperal infection. Tho
metallic tube is inserted through the internal os up to the
fundus of the womb. While the operator's right hand intro-
duces the tube, the left hand grasps the fundus uteri through
the abdominal parietes. The continuance and the frequency
of the repetition of the douche depend on the promptness and
permanence of the uterine contractions.
This same method of treatment has been employed with
great success by Dr. Albert H. Smith.
ANEMIA AND CHLOROSIS.
Basham's iron mixture, with the addition of fractional
doses of strychnia, has been found very admirable in its
effects. There are so many different recipes for making this
celebrated mixture, that the one is here given which has
proved to be the best :
R Tinct. ferri chloridi
Acid acetic, diluti ............................................... fjf ss.
Liquor, ammoniae acetat ...................................... f iijss.
Curacoae,
Syrupi simplicis ........................................... aa f^j.
Aquse ...................................... ~ ............ q. s. ad f viij. M.
SiO. One tablespoonful after each meal.
The following formula makes another very elegant and
generally useful preparation of iron :
R Tinct. ferri chloridi ............
Acid, phosphoric! diluti
Spts. limonis
Syrupi simplicis ........................... .
Aquae ...................................................... q. s. ad f^ vj. M
Sio. One tablespoonful after each meal.
Tlie Medical and Surgical Diseases of Women. 91
The dilute phosphoric acid is added both because it is a
valuable nerve-tonic, and because it has the property of dis-
guising the styptic taste of the iron ; so much so that children
readily take this mixture.
There are two other tonic preparations which are prescribed
very frequently in the Hospital of the University of Penn-
sylvania, and with capital results. One of them is Blaud's
pill, which Niemeyer extols so very highly :
R Pulv. ferri sulphat. exsiccat.
Potass, curb, purse aa 3 ij.
Syrupi q. s.
Ut fiat massa dividenda in pilulas, No. xlviij.
During the first three days one pill is to be taken after each
meal. On the fourth day four pills are taken during the day,
on the fifth day five pills, on the sixth day six; that is to say,
two pills after each meal. For three days more six pills are
taken daily ; then the dose is to be increased by one pill daily
until three pills are taken after each meal. On this final
dose the patient is kept for three or four weeks as the case
may be. In stubborn cases the dose has been increased to the
number of five pills thrice daily, and no other bad effects have
followed it than a feeling of fullness in the head. This im-
munity is probably owing to the conversion of the iron sul-
phate into a carbonate.
The other preparation is a valuable alterative tonic :
R Hydrarg. chloridi corrosivi gr. i.
Liq. arsenic! chloridi f^sa-
Tinct. ferri chloridi.
Acid, hydrochloric! dil aa f^iv.
Syrupi f iij.
Aquae q. s. ad fg vj. M
SIG One dessertspoonful in a wineglassful of water after each meal
Anaemic and chlorotic patients fatten and thrive wonderfully
on this mixture. Dr. Goodell calls it the Mixture of Four
Chlorides. It should not be given for a longer period than two
weeks at a time.
5)2 Notes of Hospital Practice.
The following tonic pills are much prescribed at the Gynae-
cological cliuic of the Hospital of the University of Penn-
sylvania :
R Acid, arseniosi.
Strychnia sulph aa gr. 3*5
Ext. belladonna gr.
Cinchoniae sulph gr. jsa.
Pil. ferri carb gr. ijss. M
Etft. pil., No.j.
R Acid, arseniosi gr. -fa
Cinchonise sulph gr. jss.
Ferri et potass, tart... gr. ij. M.
Etft. pil, No.j.
The sulphate of cinchonia in these pills may be advantage-
ously substituted by a proportionate dose of sulphate of quinia,
the former being used simply on account of its cheapness.
One pill may be given after each meal.
THE MENOPAUSE.
The diet is restricted and all stimulating foods are avoided,
even though the patient may feel weak and indisposed to ex-
ertion. Alcohol and fatty foods are strictly prohibited. So,
too, are butter, meat and fried foods. What is allowed is
light and digestible. Moral suasion has been found to be of
essential importance. The change of life through which she
is passing is explained to the patient, and her confidence thus
gained. Exercise, fresh air, sunlight, gymnastic exercises,
bathing and horseback riding are the chief hygienic indica-
tions. If the patient is feeble, with a tendency to the tubercu-
lous diathesis, care is had that she is not placed upon an ex-
hausting treatment. Where the liver is congested, occasional
doses of blue pill 3 to 5 grains once every fourteen days
are prescribed. If calomel is not borne, Dr. Pepper gives
Epsom or Rochelle salts. The nervousness is quieted by doses
of the bromides. Assafcetida and valerian have also been
found to be very useful. Excellent results have, in some
The Medical and Surgical Diseases of Women. l)f>
cases, followed the use of 2-grain doses of the monobromide
of camphor, given every two hours until 10 grains have been
ingested. The symptoms of circulatory disturbance are best
combated by digitalis. Where plethora exists, veratrura
viride is given.
The following is an excellent anti-spasmodic:
R Acid, hydrocyan. dil gtt. ij.
Sodae bicarb gr. v.
Tinct. valeriani 9 j.
Zingiberis syrupi Tr^x!.
Aquae f 3 iij. M
Sio. In water, thrice daily.
THE DIAGNOSIS OF PREGNANCY.
"A married woman comes to the clinic to-day desiring to
know if she is pregnant. The usual signs of pregnancy are
known to you all. In the present case, the woman tells me
that her monthlies have -been regular ever since her marriage,
but that she has increased in size, has felt what she supposes
are foatal movements, and, in fact, deems herself to be about
eight months gone. Upon examination, I find the breasts
unswollen, and without the areola of pregnancy surrounding
the nipple. The regularity of the menses is a very strong
presumption against pregnancy, but I shall look further. By
flexing the legs upon the abdomen, and so relaxing the recti
muscles, I am able, with one finger in the vagina and the
other hand on the abdomen, to map out clearly the size and
position of the womb. It is of the usual virginal size,
and in the usual position. Let me call your attention
to a sign not often spoken of in the books, viz., the con-
dition of the cervix. My finger placed upon it tells me
that the cervix uteri is as hard and as unyielding as gristle.
In pregnancy, even in the earlier mouths, the cervix becomes
soft and flaccid. This happens almost invariably, and the
hardness of the cervix here enables me to say with much
r,'onfidence, that I do not think the woman can be preg-
y4 Notes of Hospital Practice.
riant. She may possibly be in the first or second week, but 1
consider it extremely unlikely. You may adopt the follow-
ing general rule of diagnosis : When the cervix feels as hard
as the tip of your nose, pregnancy does not exist; when it
feels as soft as your lips, the womb probably contains a foetus.
This woman has had no morning sickness, and her breasts,
upon pressure, yield no milk, not even any moisture. Even
early in pregnancy, as a general rule, the nipples will yield a
drop or two of milk, when squeezed. Her bowels are regular,
and she experiences no difficulty in voiding her urine, and on
the other hand, no tendency to too frequent micturition. I think
that the results of my examination preclude the possibility of
pregnancy." Dr. Goodell.
PUERPERAL, FEVER.
The treatment pursued by Dr. Ellerslie Wallace is that of
oleeding bleeding the fever out, no matter whether it require
the loss of twelve or thirty-five ounces of blood. When the fever
is entirely subdued, the patient is given 3 grains of opium
of the watery extract of opium. It is then the custom to
take a piece of flannel, broad enough to cover the distended
belly, and after squeezing it out of hot water and rubbing
some oil and laudanum well into it, to apply it to the disten-
ded surface, covering it with a bit of oiled silk or carded cot-
ton, and pinning a bandage round the body loosely over all.
Together with the first dose of opium, the patient is given
from 10 to 12 grains of calomel this to re-establish the
secretions. At the same time some nourishment is adminis-
tered, in the shape of a little milk and some beef-tea, or a
mouthful or two of some delicate broth.
When convalescence begins the amount of opium is dimin-
ished, and of broth increased, and the bowels are unloaded by
means of a warm-water enema. This for puerperal peritonitis.
Puerperal metritis is treated by leeches, instead of venesec-
tion, together with opium and calomel.
Tlie Medical and Surgical Diseases of Women. 95
Dr. Goodell treats this disease by intra-uterine injections of
a warm 2 per cent, solution of carbolic acid. Ten-grain dose*-
of quinia are given every four hours until marked cincho-
nism is produced. Morphia is administered in doses suffi-
ciently large to relieve pain. The whole abdomen is painted
with the compound tincture of iodine and covered with a large
mush poultice. If it is deemed necessary to open the bowels,
large doses of calomel are used.
DYSMENORRHCEA.
Where this condition is due to stenosis and flexion, Dr.
Goodell does not believe in incising the cervix uteri, as some
New York gynaecologists advise, but finds by placing the
patient under ether and using very powerful dilators, whose
blades do not feather, that it is very rarely needful to incise.
In using these dilators, which have no shoulders, he first in-
serts the instrument right up to the fundus of the womb, and
then withdraws it half an inch before beginning to dilate.
Another favorite method consists in taking some pieces of
slippery elm bark, whittling them down to the size of matche*,
tying a string to each piece and packing the cervical canal
with them. The only danger to be guarded against in using
these slips, is that of pelvic peritonitis and cellulitis.
THE DIAGNOSIS OF OVARIAN CYST.
" Ovarian cyst is distinguished from dropsy in the following
manner : In a case of ascites, the abdomen, when the patient
is placed on her back, is flat on top and bulges out at the
sides. Here there is a projection on top and not so much
bulging out at the sides. In ascites, the intestines float up to
the top, and we get resonance upon percussion. In this
woman's case, both superficial and deep percussion reveal
only flatness. In cases of ascites, when the fluid is allowed
to settle, there is usually resonance on the top of the abdo-
96 Notes of Hospital Practice.
men, and dense flatness at the sides. Here there is quite ap-
preciable resonance at the sides. Examination of the exter-
nal genitals, vagina, womb, and breasts, which have withered,
excludes the possibility of pregnancy. There is one most cer-
tain way of settling the question, and that is by means of the
aspirator. The fluid of ascites is straw-colored and limpid ;
that of a monocyst is perfectly clear and limpid, like spring
water ; that of a holycyst is thick, dark and turbid, from the
presence of disintegrated red blood corpuscles: that of an
oligocysfc, which I suspect this to be, is usually of a milk-
and-water, or of a light brown color. I should not think of
tapping a polycyst unless I were ready to proceed at once to
operate. The fluid is so intensely acrid and irritating that
the escape of a few drops into the peritoneal cavity might set
up a violent peritonitis, and rapidly destroy life." Dr. Goodell.
LACERATION OF THE PERESTJSUM.
Dr. Goodell advises the immediate operation which he has
invariably found to be very successful in incomplete lacera-
tions. In complete lacerations, however, it has not proved so
successful as the secondary operation. In the primary opera-
tion, in order that the sutures may be most accurately put in,
he recommends that ether be given, and that a sponge be
placed high up in the vagina so as to stop the flow of the
lochia, which embarrasses the operation. The stitches are
made as in the secondary operation, and merely twisted to-
gether. In the secondary operation, if the sphincte ani is
involved, he always imbeds the first two stitches. On the
eighth day all the stitches are removed, except the lowest.
The faeces are then softened by an injection of warm sweet
oil, and the bowels moved twelve hours later by a dose of an
ounce of castor oil, aided, if necessary, by a-n injection. After
the bowels have been emptied the remaining stitch is removed.
DP. Albert H. Smith uses the Baker-Brown needle for
putting in the stitches. He always puts the first stitch in
The Medical and Surgical Diseases of Women. 97
above, making that stitch draw thoroughly together the mar-
gins of sound tissue above the laceration. He believes in
imbedding the wire all the way round in the tissues, so that
when the ends of wire are drawn together there is no pocket
left behind the stitches. He always tightens the highest stitch
first, thus protecting the tissues below from the flow of blood.
ABORTION.
" The treatment divides itself into two heads : the prevent-
ive and curative treatment. The preventive treatment is that
by means of which we prevent the repetition of abortion.
Here a knowledge of all the causes is indispensable. If
plethora, anaemia, or nervous irritability exist, they should be
modified or removed. If there is syphilis in either of the
parents, they must undergo a prolonged anti-syphilitic and
tonic treatment. This treatment must be steadily pursued for
several years. Where the abortion is due to any local dis-
order, such as chronic eudometritis, hypertrophy, prolapse,
retroflexiou, or erosion of the womb, the patient must be
placed upon a steady course of treatment for the removal of
these causes. Suppose, however, that we are called in to pre-
vent the occurrence of a threatened abortion, what shall be
done? If a syphilitic mother become pregnant, she must be
subjected to a mercurial treatment and the local condition
thus modified. If the ovum be already diseased, it will be
impossible to prevent abortion. Indeed, under such circum-
stances, abortion would be a most fortunate circumstance, and
on no condition should we attempt to balk nature in such a
case.
The first question we should ask ourselves in all cases of
threatened abortion, is: Why is it threatened? Upon the
answer to this question depends all our treatment. If the
ovum be diseased or dead, do not try to prevent the abortion.
The family history will enable you to determine whether the
o^uin be diseased ; if the product be dead, you will have the
98 Notes of Hospital Practice.
signs of death in utero. Suppose, however, that the product
is not dead and not diseased, shall the abortion be prevented ?
The next question you must ask is : Can I prevent it ? The
embryo may be so far expelled that it would be worse than
useless to interfere. The answer to this question depends on
the dilatation of the os and the amount of hemorrhage. If
the hemorrhage has been large, and the amount of blood lost
considerable, the probability is that the utero-placental con-
nections are so separated that abortion must ensue. Should a
vaginal examination show the os uteri to be well dilated, and
the membranes bulging, matters have gone so far that you
cannot hope to prevent abortion, and therefore should assist it.
There are various remedies for the hemorrhage. A drachm
of the fluid extract of ergot may be given every three or four
hours. I prefer the old wine of ergot given in doses of 2
drachms every hour or so. In addition to the ergot, the
books tell you to apply cold cloths, ice, and vinegar to the
abdomen, and to give gallic and tannic acid, or acetate of lead,
internally. I don't believe in any of these remedies. They
are not half direct enough for me. If ergot does not control
the bleeding, the next best thing you can do will be to tampon
the vagina. A tampon acts in two ways: (1) it plugs the
vagina ; and (2) it stimulates the uterus to increased efforts.
Never, however, put in a tampon unless you have given up
all hopes of preventing the abortion. If you don't happen
to have sponge-tents, tear up any napkin or piece of cloth that
comes to hand and plug up the vagina. Sometimes I have
had most excellent results from tamponing the mouth of the
uterus with a sponge-tent or laminaria.
Now, as regards the curative treatment. If abortion occur
during the second or third month, strive to secure a complete
evacuation of the uterus. Otherwise the placenta will remain
behind, and, becoming detached in the course of a day or so,
will give rise to very serious hemorrhage. If the abortion
occur in the fourth, fifth, sixth or seventh months, the mem-
branes may be ruptured without danger if the hemorrhage
The Medical and Surgical Diseases of Women. 99
proves excessive. When the child has been expelled, intro-
duce your finger into the cavity of the uterus, and feel for the
afterbirth. If it still remains in the cavity, it must be re-
moved at all hazards. Have the woman brought to the edge
of the bed, place one hand upon the abdomen, and insert a
finger of the other hand into the uterus. Press the uterus
well down upon your finger inserted into it, and scrape away
until you have removed all the afterbirth. Never leave this
work to nature, but see to it yourself at once. Where the
placenta and membranes cannot be removed by the finger,
various instruments have been devised for seizing them and
bringing them out. Hodge's modification of Everett's bullet
forceps is an entire failure, for the simple reason that you
can't hold on to any foreign body after you have seized it
with this instrument. Dewees' hook is not open to this ob-
jection, but it is so sharp that it might do much injury. The
only instrument that has proved efficient is this species of
duck-bill forceps which I now show you. I defy anything
to get away which has once been caught by this instrument.
If the placenta and membranes have begun to putrefy when
you remove them, wash out the cavity thoroughly with some
antiseptic injection.
Suppose that there is a hope of preventing abortion, what
must you do ? Put the woman to bed and give her 2 grains
of opium by the rectum. Or else you may use a rectal sup-
pository containing a grain of the extract of belladonna,
and 1 grain of the watery extract of opium. Opium may be
given hypodermically where the case is an urgent one. The
bromides, too, should be freely administered in doses of from
25 grains up to a drachm. When the symptoms are very
acute, ether or chloroform may be inhaled. Occasionally,
where the woman is plethoric, from six to eight ounces of
blood should be taken from the groin by leeches, or from the
arm by venesection. Dry cups or mustard plasters may also
be applied to the sacrum.
When abortion takes place, the symptoms will generally dis-
100 Notes of Hospital Practice.
appear. There willl be, perhaps, a lochial discharge for a
day or two. You must now employ the after-treatment for
labor at term. Keep the woman in bed for two weeks or
more. Regulate her bowels by mild saline laxatives; do not
use enemata at this time. Be careful, also, not to feed the
patient too highly. Do not allow any meat for the first week.
Ergot should be given steadily to promote the proper sub-
involution of the uterus. When the patient gets up, put her
on a tonic treatment, and impress it upon her that she is still an
invalid, and must take no violent exercise. At her next men-
strual period the flow will probably be excessive. This should
be treated by rest and by saline laxations. The vagina should
be well cleansed with astringent solutions, and ergot, gallic
acid, and cinnamon tea administered." Dr. R. A. F. Penrose.
TREATMENT OF THE FUNIS.
As soon as the child cries lustily Dr. Goodell cuts the cord,
and the umbilical portion being firmly held by the thumb
and forefinger, the free end is " stripped " of Wharton's jelly
and of any blood that may remain in it. Any blisters of
Wharton's jelly which remain unemptied after this "strip-
ping," are nicked and squeezed out. After the removal of
the pressure of the thumb and forefinger, all bleeding usually
ceases, and then the cord is tied. No subsequent dressing is
thereafter used, for the cord rapidly dries up without smell,
and drops off without leaving a sore behind.
GATHERED BREASTS.
When an abscess forms in the mammary glands, Dr.
Goodell practices an early incision. If the pus lies deep, or
is lodged behind the gland, a cutaneous incision is first made,
a grooved director is pushed into the abscess and the opening
is enlarged by the uterine dilator. The breast is then tightly
strapped with adhesive plaster and treated by a dry compress
The Medical and Surgical Diseases of Women. 101
of oakum. Should the abscess show symptoms of becoming
chronic, its walls are overstretched by an injection of a 3 per
cent, solution of carbolic acid. This overdistension is prac-
ticed in order that the acid may reach every nook and cranny
of the purulent cavity.
OVARIOTOMY.
Dr. Goodell invariably adopts the following procedure : A
5 per cent, solution of carbolic acid is used in the spray, and
all the instruments and sponges are immersed in a solution of
the same strength. The pedicle is treated by the intra-peri-
toneal method, being transfixed, tied and dropped within the
abdominal cavity. The peritoneum is always included in the
stitches which close the abdominal wound. All obstinate
bleeding points are tied with a gut ligature, but the pedicle
itself is secured by fine carbolized silk. In three cases where
there were numerous adhesions the glass drainage-tube was
employed. The dressing consists merely of salicylated cotton,
held in place by adhesive straps, the whole secured by an
elastic flannel binder. Dr. Goodell prefers this dry form of
dressing to Lister's wet dressing. The after-treatment con-
sists of opium enough to allay pain, and in one tablespoonful
of milk combined with lime-water, given every two hours for
the first forty-eight hours. As soon as wind escapes from the
bowels, the supply of food is increased.
[The patients are prepared for the operation by a soap-bath
on the previous evening, and by the administration of 1 grain
of opium at bedtime. Dr. Goodell always operates at the
hour of 11 A. M., as being the time at which the vital forces
are at their best.] When high temperature ensues, it is re-
duced by the ice-cap, which has been found to act very effi-
ciently.
SORE NIPPLES.
Chapped nipples are treated either by a 20-grain to 1 drachm
to the ounce solution of the glycerole of the nitrate of lead, or
102 Notes of Hospital Practice.
by a mixture of 2 drachms of iodoform to the ounce of the
balsam of Peru. The balsam is used because it disguises the
smell of the iodoform. Dr. Ooodell.
PLACENTA PR.EVIA.
Abnormal discharges of blood from the womb as early as
the sixth month of pregnancy, are treated by putting the
patient to bed, keeping her quiet and administering from gr.
J to gr. f of opium, and gr. ij to iij of sugar of lead in f ss.
of the infusion of rose. But slight trouble is experienced in
controlling hemorrhage until the neck of the womb begins to
dilate in earnest, and in so doing tears the placenta loose from
the uterine sinuses. When this occurs the only effective
treatment has been found by Dr. Wallace to consist in the
immediate tamponing of the vagina with sponge tents. Ca-
thartics are not thought of, even if the rectum be overloaded.
The tampon is not on any account removed until it begins to
protrude from the vagina, and when it cannot be pushed back,
though much force be expended in the effort. The minute
the first sponges are taken out their places are supplied by
fresh ones. When, in due course of time, the os uteri is found
to have expanded sufficiently, the hand is greased well, passed
far up into the uterus forearm and wrist acting as tampons
as much of the placenta is separated as may be necessary, and
the child is turned and delivered with the greatest possible
speed. The moment the child is born the placenta is removed
by the hand, and the uterus is made to contract completely by
means of ice, pressure, ergot, etc., and a bandage is firmly
applied round the patient's abdomen.
THE DIAGNOSIS OF CONGENITAL SYPHILIS.
Dr. Goodell says that congenital syphilis may appear either
before or after birth. The labor is usually premature, and
the first symptom of the disease is the hoarse cry to which the
The Medical and Surgical Diseases of Women. 103
child gives utterance. The bull soon show themselves.
The disease in uteri takes the form of placentitis, the exuda-
tion presses the blood out of the small capillaries and so
gradually starves the production of conception, or there may
be a gummy tumor or a fatty degeneration of the placenta, so
causing premature labor. In some cases the labor is precipi-
tated by atheroma of the vessels of the cord.
The child gives utterance to the hoarse cry because there
are already syphilitic ulcers on the mucous membrane of its
throat and air-tubes. Such children are always puny and
sickly looking. The bullae appear in the course of a few
hours after the birth, and are visible on either the scrotum,
hands, or feet.
If the disease does not reveal itself at birth, it usually ap-
pears some time between the second week and third month
after birth. The first symptom is excessive crying of the
child at night. This crying is caused by the incipient bone
disease pains in the bones. Its cry, too, is muffled and
hoarse. The next symptom is the snuffles ; the child's nose is
all stopped up a scalding coryza comes on. Then the child
grows wizened and thin, and its skin lies all in rolls and
wrinkles, and is more like parchment in consistency than skin.
The so-called copper maculae show themselves, or the com-
plexion gradually assumes a coffee-and-milk hue. Then the
eruption comes out all over the body, and stamps the case in-
disputably as one of syphilis.
In some instances it is very hard to find out whether the
mother has the disease herself, or whether the father has been
the only instrument of innoculation. In this connection the
curious fact has often been noted that an apparently unaffected
mother can nurse her syphilitic child with impunity, whereas
the child is sure to communicate the disease to a healthy wet-
nurse. Should a syphilitic child be knowingly allowed to
draw its sustenance from a wet-nurse, and the nurse to be so
innoculated, she has just grounds for an action at law against
the parents of the child.
104 Notes of Hospital Practice.
Treatment is generally hopeless. It is a wise law of nature
which sentences all such vitiated and diseased products to
early death. Of course all the physician can do is to subject
the child to a brisk mercurial treatment.
HABITUAL CONSTIPATION IN THE FEMALE, WITH FISSURES
OF THE RECTUM.
Dr. Goodell cures fissures of the rectum by over-stretching
the sphincter ani. To do this he inserts his two thumbs into
the rectum and then pulls them apart until either the sphinc-
ter begins to yield, or he can feel the rami of the ischia on
each side. To do this requires the exercise of considerable
strength.
As regards after-treatment, the patient is taught to go to
stool regularly every day, and to eat certain kinds of food
only. For medicine the following prescription is given :
R Ext. colocynth. comp gr. ij.
Pu'lv. rhei gr. j.
Ext. belladonnas gr. J
Ext. hyoscyami. gr. ss. M
Et in pil., No. 1 ; divide.
Sio. To be taken at bed-time.
In some cases 1/20 of a grain of strychnia is added to the
above with advantage.
AMENORRHCEA.
In amenorrhoea from anaemia and chlorosis, Blaud's pills
are prescribed. (See jLncemia and Chlorosis.}
To counteract the possible costive effect of the sulphate of
iron in these pills, Dr. Goodell advises the following aperient
mixture : the pulvis glycyrrhizse compositus of the Prussian
Pharmacopoeia, upon which he keeps patients for months and
always with benefit.
The Medical and Surgical Diseases of Women. 105
R Pulv. glycyrrh. rad.
Pulv. sennse ................................................... aa 3 ss.
Sulphuris sublim.
Pulv. fceniculi ................................................ aa !^ij.
Sacchar. purif. ...................................................... gjsa. M.
SIG. One teaspoonfol in half a cupful of water at bed-time.
Or the following :
R Ext. colocynth comp ............................................. gr. ij.
Ext. belladonnas ................................................... gr. J
Ext. gentianie ...................................................... gr. j.
Ol. carui ............ . ..... . .......................................... gtt. ss. M.
Et ft. pil., No. j.
Sio. To be taken at bed-time.
Where the disease is due to torpidity of the ovaries this
prescription is used by Dr. Penrose :
R Ex. aloes ............................................................ 3J.
Ferri sulphat. exsic .............................................. ^ij.
Assafcetidse ........................ ................................ ^iv. M.
Sio. One pill after each meal.
This number to be gradually increased to 2 and then to 3
pills after each meal. If the bowels are at any time over-
affected a return is made to the initial dose.
Another excellent prescription used by Dr. Goodell is the
following :
R Tr. ergots
Decoct, aloes comp ....... . ................. ......... q. s. ad f^viij. M.
SlO. Two tablespconfuls, twice daily.
CARUNCLE OP THE UEETHBA.
In timid women, who refuse to submit to an operation, Dr.
Goodell either mummifies the growth with crystallized carbolic
acid melted down by heat, or destroys it by applications of
chromic acid, made with the utmost care by means of a match
whittled down to a point, the excess of acid being afterwards
neutralized by injections of a strong solution of the bicarbon-
ate of sodium. If an operation is permitted, he cuts off the
106 Notes of Hospital Practice.
growth with a pair of scissors curved on the flat, and sears the
wound with a hot wire, or with Paquelin's Thermo- Caviere.
He advises the use of an alcohol lamp for heating the wire,
because when an ordinary light is used the impression upon
the operator's retina, made by the bright flame, so obscures
his vision that the cauterizing apparatus grows cool before he
can clearly see the point where the application is to be made.
He hastens the healing of the cauterized surface by occasional
applications of carbolic acid, or by dusting it with iodoform.
CANCER OP THE CERVIX UTERI.
Whenever practicable the whole cervix is removed, by
either the hot or the cold wire. If this cannot be done, Dr.
Goodell removes the malignant growth by scraping or by the
gouge forceps, and the surface is then charred by the thermo-
cautery. This radical treatment is reinforced by subsequent
applications of the ethylate of sodium. In these operations
upon the cervix he finds injections of ordinary vinegar to be
an excellent means of controlling any embarrassing bleeding.
By these means he has succeeded in curing several cases.
CYSTITIS IN THE FEMALE.
Transient cystitis, dependent upon obscure causes, Dr.
Goodell treats by rectal suppositories, containing 1 grain each
of the aqueous extract of opium, and of the extract of bella-
donna. Hysterical cases generally yield to massage and elec-
tricity. In obstinate cases of bladder trouble Dr. Goodell
warmly advocates the dilatation of the urethra throughout its
whole length by the introduction of the forefinger. In the
therapeutical treatment of this troublesome disorder, atropia
nas been found to be the most efficient remedy. It may be
combined with alkalies or acids, according to the condition of
the urine. Injections of a 2-grain solution of quinia into the
The Medical and Surgical Diseases of Women. 107
bladder, together with large doses of the same drug by the
mouth, will often improve the condition of the patient. In
very bad cases the most efficient injection, perhaps, is one of
the nitrate of silver, beginning with a weak solution and in-
creasing its strength daily, until 30 grains to the ounce if
reached. These strong solutions should not remain in the
bladder longer than ten or fifteen seconds. All malpositions
of the womb must of course be rectified, especially if they have
any bearing upon the disease.
CONICAL CERVIX UTERI.
This condition is treated either by forcible dilitation with a
strong uterine dilator, or by lateral section with a hysterotome.
If the cervix is sickle-shaped, Dr. Goodell performs the sec-
tion of the posterior lip. The subsequent treatment consists
in such local management as tends to keep the parts from
closing up.
PROLAPSE OF THE OVARIES
is best managed by the knee breast posture, and by the
administration of such alteratives as tend to lessen the con-
gestion of these organs. Among these, Dr. Goodell deems
the best to be the chloride of ammonium in combination with
the bichloride of mercury. Sometimes, however, large doses
of the bromides act very happily. He considers this disloca-
tion to be due in a great measure to the congestion of the
sexual organs, consequent upon the use of measures to pre-
vent conception, or from masturbation. He finds that pes-
saries are rarely useful in this distressing condition. But
among them he thinks Cutter's bulb pessary to be the best.
He considers prolapsed ovaries to be a very frequently over-
looked cause of many pelvic aches and pains, which are attri-
buted very generally to the womb alone.
108 Notes of Hospital Practice.
CLOSURE OF THE VULVA FOR VESICO- VAGINAL FISTULA.
In curable cases of vesico-vaginal fistula, in which the urethra
has been destroyed, Dr. Goodell has twice succeeded in wholly
relieving the patient. ' In one case this was done, by making an
artificial recto-vaginal fistula, and in the other by leaving an
already vesico-vaginal fistula intact, and in then closing up the
vulva. Whenever practicable he prefers in this unfortunate
condition, provided the urethra is unimpaired, to close up the
vagina as high up as possible, so that the marital relations
should not be interfered with. In uncomplicated cases of
vesico-vaginal fistula he prefers the use of shot to twisting of
the wires, because they form, permanent adjusters and prevent
e version of the edges of the wound.
VAGINITIS.
Non-specific and acute cases of vaginitis Dr. Goodell treats
by such hojt and emollient injections as flaxseed, or slippery
elm bark tea. When the inflammation has subsided vaginal
suppositories, containing 5 grains of iodoform, are ordered
twice or thrice daily. In the chronic forms of this complaint
he uses suppositories of tannin or iodoform, or long tampons
of absorbent cotton dipped in astringent solutions of acetate
of lead, and of zinc to which laudanum, has been added.
FUNGOUS VEGETATIONS OF THE ENDOMETRIUM.
In this condition Dr. Goodell removes the unhealthy growth,
either by the dull or by the sharp curette, or if the os is suffi-
ciently patulous, by means of a small fenestrated polypus for-
ceps. The uterine cavity is then cleansed with a saturated
tincture of iodine if the cervical canal is not very open, but
when it is gaping he prefers Monsel's solution. In the
former condition he avoids the use of the iron, because it
forms clots which cannot easily be expelled from the womb
without causing much pain. He deems the iron, however
the more efficacious treatment of the two.
The Medical and Surg-icat Diseases of Women. 109
VAGINISMUS.
Dr. Goodell had never yet been compelled to resort to the
deep posterior incision practiced by Dr. Marion Sims, although
in two cases he was obliged to snip off irritable carunculse
my rti formes. He treats this disease precisely as he would
treat an anal fissure. If the local spasm does not yield to
constitutional treatment and to vaginal suppositories of mor-
phia, belladonna, carbolic acid and iodoform, he puts the
woman under ether and forcibly stretches the vulvo-vaginal
opening either by means of the two thumbs, or by the fore
and middle fingers of each hand.
NERVOUS DISEASES.
IN THE PHILADELPHIA HOSPITAL FOB DISEASES
OF THE NERVOUS SYSTEM.
The cases found in these wards, which are in charge of Dr.
Charles K. Mills, neurologist to the hospital, are chiefly ex-
amples of chronic organic disease of the nervous system
hemiplegics from hemorrhage, thrombosis, or embolism ; cere-
bral, cerebro-spinal, and spinal scleroses ; meningitis, meningo-
encephalitis, and meningo-myelitis ; epilepsy, hystero-epilepsy,
and hysteria; brain tumors, spinal softening, and the like.
Acute cerebral and spinal disorders; neuralgias, peripheral
paralyses, local spasmodic diseases, and similar affections, are
sometimes, but not so frequently, represented.
ELECTRICITY.
In connection with the wards, a large apartment, known as
the Electrical Room, has been fitted up. It contains one of
Flemming & Talbot's permanent batteries of sixty cells, and
a fine faradic instrument from the same manufacturers. The
wards are also supplied with portable galvanic and faradic
instruments.
Dr. Mills, during the past year, has used electricity witk
marked success in the treatment of bed-sores, which, in spite of
the best of care, are apt to form in cases of spinal and cerebral
disease. The "silver-and-zinc-plate" method is the one gen-
erally employed, a silver plate being placed over the sore, and
a zinc plate (connected by a wire with the silver) on a piece of
acidulated chamois skin or paper lint, which rests on the un-
broken skin a few inches above. A weak current from the
galvanic battery is sometimes used instead of the plates, A
110
Nervous Diseases. Ill
applied to the sore is connected with the negative
electrode ; an ordinary rheophore, joined to the positive pole,
being placed upon the surface near. The seance is continued
for from five to ten minutes daily. Many cases of chronic
ulceration put into the hands of the neurologist for electrical
treatment have been cured by the galvanic plates, or the use
of the battery current. Electricity is very effectual in stimu-
lating healthy granulations.
Faradization is used in the wards to improve the condition
of palsied muscles ; and central galvanization is employed
chiefly in spinal affections.
METALLOSCOPY AND METALLOTHERAPY.
Numerous experiments in metalloscopy and metal lotherapy
have been made in the Nervous Wards, only a few of which
can be alluded to at present.
In one case of brain tumor with partial anaesthesia of the
left leg, a small zinc plate applied to this limb in an hour r
caused a sensation which was described by the patient as being
like that produced by the " battery," referring to a faradic
instrument. Other metals were tried, but had no effect.
The salts of zinc were used without success, iodide of potas-
sium being the only remedy that seemed to help the case.
Some curious results were obtained in a number of cases of
marked anaesthesia from hysteria and spinal disease, to two of
which reference will here be made.
One case was that of an unmarried woman, aged 29, sup-
posed to be an example of hysterical paraplegia and anaesthe-
sia. On two occasions plates of zinc, iron, copper, tin, silver
and gold, of about the same size and weight, were placed on
different parts of the body simultaneously ; at other times the
applications were varied sometimes one plate, sometimes two
or three were used. Many trials were made, the patient being
blindfolded, and different locations being selected for the same
plate. In five instances the patient picked out the zinc plate
112 Notes of Hospital Practice.
in from twenty to forty minutes, saying that she felt under it
a sensation which she described as tingling, or as like "pina
and needles." Twice she referred similar, but weaker, sen-
sations to the plate of iron, but other metals gave no result.
Sensation was temporarily improved, muscular power was
apparently increased; and the anesthetic limbs bled more
freely, on pricking them with needles, after the zinc was ap-
plied, until the peculiar sensations described were called forth.
This patient was kept upon the use of valerianate of zinc for
six weeks sensation, motion, and her mental condition -im-
proving. Subsequently, however, she relapsed.
A second case was that of a man, aged 28 ; an advanced
case of sclerosis of the posterior columns, with almost absolute
ansesthesia of the lower extremities. After carefully testing
the condition of sensibility and of the circulation, a small zinc
plate was applied to the right calf, and a silver plate of the
same size to a corresponding part of the left leg. In thirty
minutes he began to have a sensation as if needles were prick-
ing him under the silver plate. Two or three minutes later
he had a similar^ but weaker, sensation under the zinc on the
right limb. The plates were kept on ten minutes, during
which time he had four alternations of sensation in the two
sides. When the pricking sensation was present under the
silver plate it would be absent under the zinc, and vice versa;
but it was in each instance much more decided under the
silver. On removal of the plates electro-sensibility was de-
cidedly improved. No change of sensibility to the aesthesio-
meter or state of the circulation was produced. The symp-
toms in this case were decidedly ameliorated by both nitrate
and oxide of silver, but were not permanently benefited by
any treatment.
Dr. Mills does not believe that the theory of " expectant at-
rention " will explain satisfactorily all the phenomena which
result from metallic applications. Patients do certainly some-
times exhibit metallic idiosyncrasies whatever may be the
explanation. Ansestlvesia, even when the result of organic
Nervous Diseases. 113
disease, can be temporarily removed by applying pieces of
metal. He has observed that two metals will sometimes
produce similar effects on the same individual but, even in
these cases, he has always found that one of the two will give
rise to more decided sensations, and will be more positively
effectual in removing the anaesthesia.
In regard to internal metallotherapy, it is somewhat diffi-
cult to arrive at a decision. Irrespective of metalloscopic in-
vestigations, the value, in chronic spinal diseases, of the
preparations of zinc, silver, and other metals, has long been
known. They can also be used with advantage in cases in
which no effect is produced by external applications of metals.
The salts of silver and zinc will undoubtedly bring about
amelioration of serious symptoms in cases in which these
metals, when applied to anaesthetic limbs, will be selected by
patients in preference to others, because of the peculiar sensa-
tions which they cause.
MASSAGE AND SWEDISH MOVEMENTS.
Both massage and Swedish movements are employed to a -
considerable extent, some of the nurses being trained for this
work. Massage is found to be of benefit, even in old cases
of paralysis, serving to keep up nutrition and temperature,
and preventing trophic changes. In neuralgic and hysterical
cases it also often proves of great service-.
In the same room in which the permanent electrical instru-
ments are kept, are some simple forms of apparatus for the
movement treatment, such as a crossbar adjustable at various
heights, a leaning cylinder for exercising the muscles of the
trunk, a stool of the proper height and size for sitting move-
ments, and a lounge or couch so hinged as to be capable of
being inclined at various angles. The patients are taught to
practice movements with or without assistance, according to
the nature of the case.
A movement treatment, without apparatus, is also often
! 1 4 Notes of Hospital Practice.
used. The kinds of movements usually resorted to, without
.appliances, are the passive, or the duplicated active. Syste-
matic passive movements are employed for the purpose of
preventing, as far as possible, atrophy and deformities. Joints
.re kept in a healthier condition through the agency both of
massage and these passive movements. Duplicated active
movements are used in those cases in which the loss of power
in sclerotic or paralytic patients, for instance, is not absolute.
In conjunction with faradization this method of treatment
often results in the marked improvement of the paralyzed
limbs, palliating symptoms, and improving circulation and
nutrition even of palsied limbs.
THE ACTUAL CAUTERY.
The actual cautery, either alone or conjoined with other
remedies, is frequently resorted to in the treatment of epilepsy,
and of chronic spinal diseases. The ordinary cautery-iron,
with a button shaped like the blunt end of an olive, lias
usually been employed, but recently the hospital has obtained
a Pacquelin cautery, in which the vapor of pure benzine is
forced by an air-blast upon a piece of hot platinum. Super-
ficial applications to the nape of the neck, or along the spinal
column, are made every two or three days. The intervals
between epileptic seizure have been extended from days to
months by the use of the cautery
THE TREATMENT OF SYPHILITIC BRAIN DISEASE.
The wards are nearly always well supplied with syphilitic
affections of the brain and cord. Iodide of potassium in
energetic doses is largely employed. Mercurial inunction has
also been extensively tested, and in a few instances with
striking results. From a drachm to 1 J drachms of mercurial
ointment is used daily, or every other day, the treatment being
persisted in until seme effect is produced, or good reasons
Nervous Diseases. 115
arise for its discontinuance. Before inunction, the parts to
which the ointment is to be applied are well sponged with
warm water. Strict attention is paid, at the same time, to
diet and hygiene.
TREATMENT OF SPINAL, SCLEROSES.
For the various forms of spinal scleroses, and particularly
for posterior spinal scleroses, or looomotor ataxia, the salts of
silver the nitrate, phosphate, or oxide are generally found
to be the most efficacious internal remedies. They are used
in doses of from to a grain, and are often combined with
some bitter tonic, as the extract of gentian or quassia. Elec-
tricity, in the form of moderately strong gal vanic currents, is also
much used ; stabile xsurrents to the spine, and labile currents to
the limbs being the most common methods of application. Early
in posterior scleroses large doses of ergot are often prescribed.
THE TREATMENT OP CEREBRAL AND SPINAL EXHAUSTION.
Preparations of phosphorus are used in the treatment of
cases which show signs of cerebral or spinal exhaustion. A
favorite preparation of this substance is the oil of phosphorus
of the Prussian Pharmacopeia. This oil is administered
according to the following formula, which is also used at the
Hospital of the University of Pennsylvania ;
R Olei phosphorati
Olei ganltheriie
Mucilag. acacitt .......................................... q. s. ad f^j. M.
Sio. One to two teaspoonfuls three times daily.
The oil of phosphorus itself can be prepared by the follow-
ing process : u Into 5 fluid drachms of pure almond or olive
oil, contained in a glass flask, drop 3 grains of transparent
phosphorus. Place the whole in a water-bath at 175 F.,
and agitate until dissolved."
116 Notes of Hospital Practice.
CALABAR BEAN IN DEMENTIA PABALYTICA
Calabar bean is prescribed in dementia paralytica, cases of
\vhich, in the early stages of the disease, sometimes find their
way into the Nervous Wards. If not promptly relieved,
they are transferred to the Insane Department. Pills of the
ext. physostig. venenas, each containing l/'g to the 1/3 of a
grain, are given three times daily, the treatment being per-
sistently continued and the effects of the drug constantly
watched. Rest, nourishment, and counter-irritation to the
head or nape of the neck are conjoined with the calabar bean.
GENERAL NOTES.
Cannabis indica, hyoscyamus, conium, morphia, chloral,
and bromide of potassium are used to fulfil various indications,
such as tremor, headache, sleeplessness, mental symptoms, etc,
APOPLEXY.
In the treatment of the apoplectic state the patients do not
stand depletion well. Bleeding is seldom employed. Sup-
porting measures are often found to be necessary to carry the
cases successfully through the attacks.
THREE INTERESTING CASES OP SPINAL DISEASE.
CASE I. The patient, a sailor, was brought into the hos-
pital with a history of a fall of thirty feet from the rigging
of his ship while at sea. He fell partly on his head and
partly on his back. When picked up he was unconscious,
and remained so for fifteen minutes. Upon regaining con-
sciousness he found that his right arm and leg were entirely
paralyzed, and the left arm almost entirely so. The patient
received no treatment whatever while at sea.
Since admission the patient had been carefully examined
Nervous Diseases. 117
and found to be free from any disease of his heart, lungs,
liver, or kidneys. The ophthalmoscope revealed a slight optic
neuritis, but not enough to indicate any serious disease of the
brain. When he walked he carried his head somewhat for-
ward. The effort to straighten the head gave the patient
pain. At the point of junction of the cervical and dorsal
spine some thickening and induration were found. The right
arm had not entirely recovered its power. He was unable
either to extend or close the fingers of that hand. There was
some atrophy of the muscles of that hand. The circulation
of the same limb was also found to be very defective. The
left hand and arm exhibited the same conditions, but to a
lesser degree than the right arm. The man's walk was pecu-
liar. The right leg was stiff and trembled when he walked.
Upon stripping the limb the feet were found to be abnormally
extended. Attempts to bring the foot up to a right angle
were attended with great trembling of the member and
marked tension of the tendo Achillis. The tendon reflex of
the patella of both legs was most marked. There was no
decided impairment of the sensation of either touch or pain
in the feet. Contraction of the muscles under the faradic
current was slightly impaired in both legs and arms. Now
and then trembling could be produced by pressure upon the
lower part of the. spinal column.
In debating the case, two difficulties were encountered.
First, in connection with the nature of the original injury;
and second, as regarded the present nature of the disease.
Concerning the first point, concussion of the spine seemed
hardly possible, since it could not account for the paralysis of
the muscles of three extremities. It seemed more probably
to have been a case .of apoplexy of the cord. It was con-
cluded, however, that the .effiision of blood could not have
been a large one, since there was no paralysis of the left leg,
no urinary difficulty, and 110 pronounced tendency to the
formation of bed-sores.
Concerning the second point to .be decided, it was though*
1 18 Notes of Hospital Practice.
by Dr. James H. Hufcchinson that the symptoms then present
pointed conclusively to an involvement of the lateral columns.
This opinion was strengthened by the presence of spastic mus-
cular contractions. The absence of anaesthesia proved that
the posterior columns could not be seriously aifected, and the
absence of analgesia seemed to show the same to be true of
the gray matter. It was thought that simple concussion of
the spine was sufficient to produce inflammation of the lateral
columns.
As soon as the patient entered the wards a blister was
applied to the seat of induration in the back, and bromide of
potassium administered internally. When it was seen that
inflammation of the cord existed, 1/ 16 of a grain of bichloride
of mercury was ordered four times a day. Later he was put
upon gr. x of potassium iodide thrice daily, which dose was
subsequently doubled. It was remarked, in connection with
the early history of the case, that ergot and belladonna would
have been the proper remedies to employ immediately upon
the reception of the original injury.
For the future, occasional blisters were ordered and rest was
enjoined. Strychnia and electricity were regarded as injurious.
CASE II. A farmer, with a good family history, who had
spent a day in very hard work, and during the following
night had been much exposed to cold and wet. This impru-
dence, which took place eleven months before his admission
to the hospital, was followed by loss of power in the lower
extremities and complete paralysis of the bladder.
For two or three months after this period the patient had
shooting pains in his legs, and was much troubled with noc-
turnal delirium.
The man was carefully examined by Dr. DaCosta after his
admission, and found to be suffering from marked paraplegia
without involvement of the rectum or bladder. The strong
faradic current elicited no response whatever in either leg,
except from the flexors of one of the big toes ; using the con-
tinued current the same results were observed.
Nervous Diseases. 119
The case was regarded as a typical one of acute spinal par-
alysis a rare form of disease in the adult in which the
lesion was in the anterior horns of the spinal cord. The loca-
tion of the lesion was thought to account for the entire loss of
electro-muscular contractility, while sensation was so little
impaired. It was also thought to account for the absence of
ectal and vesical difficulties and of bed-sores.
CASE III. A shoemaker, who stated that his troubles
dated back to an attack of rheumatism in his legs. This
rheumatic attack lasted about three weeks. Pains in the back
and legs were associated with rheumatism.
When admitted to the hospital the man complained greatly
of pains in the limbs and back, and of loss of power in the
lower extremities. He still walked with difficulty and pain,
but the local tenderness and discoloration had gone. It was
difficult to decide whether the pains complained of were due
to the rheumatism in the extremities. It was concluded that
they were not. The man improved very rapidly tinder the
use of the iodide of potassium and ergot, and was discharged
entirely cured, as it was supposed. Ten days afterward, how-
ever, he was again admitted. Upon questioning him closely
it was discovered that he had spent all the time since his dis-
charge in walking about the city in search of employment.
After his return to the wards he began to lose power in his
legs steadily. The pains in his back and legs returned, and
he spoke of a feeling of great constriction around his waist.
Still later the legs began to atrophy, and still the loss of power
remained. The electro-muscular contractility was very much
diminished, while the sensibility seemed to be slightly deficient
in both of the lower limbs. The capillary circulation was
very defective, the blood circulating very irregularly in the
superficial tissues. Reflex sensibility still remained intact.
The muscular sensibility had gradually increased.
It was concluded very early in the progress of this case
that it was one of rheumatic paralysis of the cord, or rheumatic
spinal myelitis.
J20 Notes of Hospital Practice.
Anatomically speaking, it was pointed out that the lesions
in Cases II and III were the same, both being located in the
anterior horns, but in Case II there was no rheumatism, and
the spinal paralysis came on at once; while in Case III the
rheumatic origin was plain, and the spinal complications came
on at a later period. The treatment of Case III was by gr.
xv of the iodide of potassium thrice daily, with a little iron
nd locally friction.
In the discussion of Cases II and III some very interest-
ing points were brought out. Particular attention was directed
to the rapid atrophy of the muscles of the lower extremities in
both of the cases. This atrophy was emphasized as being the
most typical and constant symptom of this class of affections,
the rapidity with which this atrophy progresses being in pro-
portion to the acuteness and persistency of the attack.
Another fact, to which particular attention was directed,
was that this atrophy, as a general rule, is not permanent.
In caiaes where recovery has been more or less complete, the
limbs are found to have regained, to a greater or less degree,
their normal shape and power, the completeness of the return
of the limb to its normal shape being dependent, of course,
upon the completeness of the patient's convalescence. Com-
plete restoration to power and health was regarded as rare.
It was argued that the real extent of the damage done de-
pended upon the number of trophic cells which had been
destroyed. If enough of them remained intact, when the
morbid process had ceased, to minister sufficiently to the sup-
ply and nourishment of the atrophied muscles, it was easy to
restore their for a time lost functions by means of proper
nerve-food, friction and electricity in the shape of galvanism,
and in the later stages by the hypodermic use of strychnia.
The question arising as to whether the tape-measure was
the only means of judging definitely of the condition of the
affected muscles, it was pointed out that when it was found
upon trial that the faradic current when applied to the affected
muscles began to give better results, and when the muscles
Nervous Diseases. 121
began to respond and contract, though feebly, it might be ac-
cepted as a sure sign of returning health, for it proved con-
clusively that the muscles were becoming more active, and
that the paralysis had reached its height.
It was thought that the same conclusion could not be drawn
from the use of the continuous current, the muscles respond-
ing to this current so soon that it could not be regarded as
any gauge at all.
Attention was called to the facts of the entire absence of
rectal and vesical paralysis, and of bed-sores, in Cases II and
III.
In one point it was shown that these two cases had not been
typical ones of their kind, viz., in so far as the reflex nerv-
ous functions had not been in the least impaired in either case.
The treatment was limned out by Dr. DaCosta, as having
consisted at first of local blood-letting in the neighborhood of
the spine, occasional purging, and large and continuous doses
of ergot. This at first; later the indications were met by
large doses of the iodide of potassium, and by the application
of systematic friction to the legs. Later still, it was thought
that small doses of strychnia should be administered hypo-
dermically, and when muscular motion returned, that the
farad ic current should be employed.
CHOREA.
Dr. Wharton Sinkler has controlled the twitchings of
patients with this disease by the continued hypodermic injec-
tion of from 3 to 5 drops of Fowler's solution. In some
of the instances, the injections were followed by a good deal
of local irritation.
Dr. H. C. Wood has treated successfully several cases of
this disease, with a saturated tincture of the rhizome of dra-
contium. The dose at first is 60 drops thrice daily, and it is
gradually increased to 90 drops. Particular care is taken that
the preparation of the drug used is a reliable one.
122 Notes of Hospital Practice.
PARALYSES OF THE RECURRENT LARYNGEAL NERVE.
Nerve tonics, such as strychnia, phosphorus, iron, and cod-
liver oil, are used. In the so-called instances of hysterical
and nervous aphonia, a sponge-probang is moistened and
brought into contact with the vocal cords, which are thus
thrown into a state of spasm and so brought together. The
same effect is produced in other cases by sprays of ether
projected upon the part, or by inhalations of pungent sub-
stances.
"When all else fails, electricity is employed and is applied
directly to the paralyzed muscle.
In using electricity, the plan pursued by Dr. Cohen is to
place one electrode directly over the crico-thyroid ligaments
outside, and then to carry the other electrode into the larynx
and place its point in contact with the cords, or between them.
The electrode in the throat is only kept in position a few
seconds at a time. Cures are often effected in this way by a
single application.
Where intra-laryngeal electric excitation is not possible, the
percutaneous method is tried. This consists in passing a cur-
rent from one side of the neck to the other, and so through
the larynx. Or, the patient is placed upon the insulating
stool and a spark is drawn from the cricoid cartilage with the
knuckle.
In cases of hysterical aphonia a cure is often effected
by the mere introduction of the laryngeal mirror, the
patient being given to understand that this is the curative
procedure.
Another method often tried is to stand behind the patient
and grasp the thyroid cartilage between the thumb and fore-
finger, while at the same time the middle finger is placed
under the cricoid cartilage, pulling it up and in front of the
thyroid. In this way the vocal cords are stretched and made
tense, and so caused to vibrate by means of the inspiratory
current.
Ne/vous Diseases. 123
TETANUS.
Systematic feeding of patients with liquid and strengthen-
ing food at short intervals, has been employed by Dr. H. 0.
Wood with very good results. The food is given at intervals
of every two or three hours, and consists mainly of milk,
with a small quantity of alcohol. In severe cases all solid
food is avoided. As regards medicines, the patient is brought
well under the influence of the bromide of potassium by an
initial dose of from 2 drachms to J an ounce, to be followed
by ^ a drachm to a drachm every three or four hours. To
force sleep at night, 30 grains of chloral are given at bed-time
with some opium. Chloral is also used, when necessary, in
the day-time. Nitrite of amyl and chloroform are never used
steadily, but are employed from time to time to stop violent
spasms. Where there is much cerebral congestion, a blister
is applied to the nape of the neck.
WEAVER'S, VIOLINISTS, AND IRON PULLER'S PALSIES.
CASE I. W. B. C., by profession a violinist, has been a
steady player for twenty years, averaging six hours out of
every twenty-four. Patient presented himself for treatment
January 27th, 1875, saying that one year before that date he
first noticed a spasm of the flexors of the ring and little fingers
during an attempt to lift them from the cords of the violin.
When playing he had pain in the ulnar region of the arm.
Used to play first violin ; but for a year had been obliged to
play second violin.
Sensation and electro-muscular contractility remained unim-
paired.
He holds neck of violin between the thumb and forefinger,
touching the cords with the other fingers. He occasionally
experiences a momentary cramp in the fourth and fifth fingers
in lifting them off the cords. Was able to play the piano with-
out any difficulty.
124 Notes of Hospital Practice.
September 2,7th, 1875. Trouble still continued in the third
finger of the left hand, which hung on his violin string when
it should be raised off it. Doubtful of any improvement
Advised galvanization of flexors and extensors, one pole in
axilla, the other stroked over the muscles.
CASE II. W. V., set. 35 years, a heater in a rolling mill,
who worked in an iron foundry at Catasauqua, pulling the
iron in and out of the furnace.
Patient had been married and had four healthy children.
He denied syphilis, and had always enjoyed good health up
to the date of his present troubles. He came for treatment on
March 25th, 1872, with the statement that after working three
successive terms at the furnace, and sleeping from seven to
nine A. M., he went to a pic-nic. The next day when he
woke up he found his hands swollen and stiff. This was on
a Friday. He did not resume work until Monday, by which
time the swelling of the hands was less marked. He worked
steadily for a month, the strength in his hands failing, the
grip becoming weak, with a feeling of numbness but no loss
of sensation.
During this time his wife died, and he was much distressed.
For a month after her death he worked, and at the end of that
time was obliged to stop. Since then the strength in his
hands has steadily failed, commencing in the hands and
extending up the arms.
There was some pain in the small of the back, some diffi-
culty in articulating, and also in " hawking." No dyspeptic
symptoms. Bowels very irregular. Passed urine but once
during the day, and it never drippled away. No blue lines
on the gums.
There was absolute loss of power in the deltoids, though
the fibres of the muscles contracted. No power in biceps,
and the greatest palsy in the flexors of the fingers and hands.
Able to raise wrist, and to pronate and supinate arms. Loss
of power in the triceps muscles not so marked as in the others,
the right triceps being stronger than any other arm muscles.
Nervous Diseases. 12o
Pectoral muscles weak. All the muscles were about equally
atrophied, and to a considerable extent.
Sensibility and localization good. Could test the distance
of points well.
Some loss of power in uvula apparent. Both right and left
arm measured 7J in. at a point three inches below the elbow.
Electric condition. The secondary induced current one cell,
three inches, moved both deltoids, most marked contraction
being obtained by placing the positive pole over the brachial
plexus, and the negative over the muscle. Electro-muscular
contractility remained in all the muscles, but was diminished
in degree except in the flexor coinmuuis digitorum. Electro-
muscular sensibility existed in both arms.
3 . ext. ergot, fl., gtt. xx., and potass. i<>did., gr. v., t. d. ; also
advised the use of galvanism.
April 2d. The dose of the medicine was diminished one-
half in consequence of its purging him. One week later it
was found necessary to discontinue it entirely for the samf
reason.
April 30th. After eighteen applications of galvanism there
was no improvement, and, returning home, he died about the
middle of May.
CASE III. J. B., set. 26 years, a weaver by occupation.
His family history has been good; so also has his previous
health l>een. Patient has been a weaver since he was fourteen
years of age, using his left hand as much as the right in
weaving. When fifteen years old he began to be troubled
with spasmodic pronation of the left hand. He stopped work
for a few weeks, and upon returning was not troubled with
it again until he was twenty-one years of age, when it
re-appeared, and has continued permanent ever since, except
when he could stop weaving temporarily.
The spasm consists of a sudden pronation of the left hand,
with a general tremor of the arm, caused by any voluntary
exertion a large, irregular tremor. Any movement of the
hand with the arm flexed is more difficult to perform than
1 26 Notes of Hospital Practice.
with the arm extended. Patient is unable to comb his hau
backwards with the left arm.
He was naturally left-handed, and when he first presented
himself for treatment at the clinic, the dynamometer registered
with the left hand 135, right 150.
Sensation was unimpaired in both hands. There was no
pain in the back of the neck ; but a " bruised " feeling in left
arm after exertion. Advised change of occupation and gal-
vanism three times weekly to arm. Dr. S. Weir Mitchell.
FACIAL PARALYSIS, FOLLOWED BY SECONDARY SPASMS
AND CONTRACTURES.
R. S., set. 46, a married woman, came under observation
late in the winter. Three weeks before, without known
cause, except that she was at times considerably exposed to
the changes of weather, she suddenly became paralyzed on
the left side of the face. Her menses had been irregular foi
six months, and she had not been feeling very strong for a
year.
Examination showed complete paralysis of the muscles sup-
plied by the external third of the facial nerve. The left side
of the face was smooth. She could not wrinkle the left half
of the forehead, nor close the left eye. The nose was drawn
very slightly to the right, and the mouth in the same direc-
tion and upwards. She could not pucker the mouth. Her
speech was somewhat indistinct, and, when eating, food often
lodged between the left cheek and the teeth, causing annoy-
ance. The conjunctiva of the left eye was usually injected,
and she complained frequently of pain and discomfort in this
eye.
The velum palati and uvula were unaffected. She had no
loss or disturbance of taste on either side of the tongue.
Smell was slightly impaired. Hearing in the paralyzed side
was normal, being neither abnormally acute, nor dull nor lost,
and she had no noises in the ear.
Nervous Disease*. 127
The muscles responded promptly to both the faradic and
galvanic currents, and the response to faradism, which was
used in the treatment, continued good.
Iodide of potassium was prescribed in doses of 10 grains
three times daily ; and faradization with a current just suffi-
cient to produce muscular contraction was employed every
other day. Positive and progressive improvement took place,
the patient gradually recovering power in all of the affected
muscles. After six weeks of treatment, however, a slight
twitching of the left angle of the mouth began to be noticed.
In a few days, this angle of the mouth was drawn up almost
constantly. The cheeks and lips began to be pressed against
the teeth, and she complained of a band-like feeling around
the paralyzed side of the month. She had, in short, an irreg-
ularly distributed, but marked condition of spasm in most of
the muscles recovering from the paralysis. Now and then a
succession of rapid twitches would be noticed in the muscles
about the angle of the mouth. Less frequently similar
twitchings were observed in the orbicularis palpebrarum
muscles, especially in its lower fibres. Any effort, under the
influence of the will, to use certain muscles or groups of mus-
cles of the left side, would cause a curious appearance of dis-
tortion and grimacing, owing to the irregular spasmodic
actions that would ensue. When the mouth .was pulled up-
wards and outwards, for instance, the eyelids would be pressed
together and the digastric muscle would be called into play.
The patient was constantly annoyed by an unpleasant feeling
of "drawing." After this condition had lasted from one to
two weeks the left half of the orbicularis oris and the zygo-
matic muscles began to feel hard and hypertrophied.
On the appearance of the spasmodic symptoms, the use of
the faradic current was transferred to the healthy or non-par-
alyzed side and a weak galvanic current, uninterrupted, was
applied to the zygomatic, orbicular and other muscles, which
were the seat of the tonic spasm or contractures. Bromide of
potassium and valeriauate of zino were administered inter-
128 Notes of Hospital Practice.
nally, and belladonna ointment was frequently rubbed into
the face. Under this treatment the patient improved, and
she was discharged much relieved, but not entirely cured, as
some contracture still remained.
The secondary contractures and spasms observed in this
case have been noted by Dr. Mills as occurring in varying
degree in a number of cases of facial paralysis. They have
been studied by Duchenne, Remak, Hitzig, Erb, and others.
No very satisfactory explanation of their occurrence has been
offered. Hitzig refers the symptoms to an abnormal excita-
bility of the medulla oblongata, which becomes developed in
a still unknown manner, in consequence of peripheral facial
paralysis. (Erb in Ziemssen's Cyclopaedia, vol. XI, p. 109.)
Dr. Mills believes with Erb, that the condition is not one of
" electrical muscle tetanus," induced by electric treatment, as
it occurs in cases in which no electric treatment has been
employed. Transient states of spasms in cases of this kind
are by no means uncommon. Assuming the doctrine of the
localization of motor centres in the cerebral convolutions to
be true, it may be that the special cervical centres for various
facial movements, temporarily quiescent during the existence
of the paralysis, as recovery takes place begin to act in an
irregular and abnormal manner.
Whatever may be the true theory of the production of these
secondary spasms and contractures, experience has proved that
they are best treated by the conjoint use of internal and exter-
nal measures. The bromides and preparations of zinc, cimi-
cifuga, hyoscyamus, arsenic and similar articles, should be
given with a view of quieting and controlling the nervous
centres, while at the same time, the patient's strength is sus-
tained by mild tonics and abundant nourishment. A weak,
stable galvanic current should be used for its antispastic effect
directly to the nerves and muscles. Mild faradization of the
antagonistic muscles of the healthy side can also be resorted
to, but it should be used with caution and not too often.
Detmold's mechanical treatment of facial paralysis can be
Nervous Diseases. 129
applied with advantage to the unaffected side with the view
of preventing and controlling contractures upon the opposite
side. This is carried out by taking a piece of tin wire, or
some similar material, and bending it at both extremities, so
that one end can be passed over the ear and the other hooked
into the angle of the mouth, thus affording a support and pre-
venting the drawing to the other side. Hypodermic injections
of sulphate of atropia, gr. l/ 10 o to I/GO* us ig n* 116 needles,
can be thrown into the spastic muscles; and here, as in so
many other cases of spasm, superficial applications of the
white-hot iron to the back of the neck, or over the muscles,
may prove of signal service. Cases of this kind sometimes
obstinately resist all therapeutic measures.
FACIAL PARALYSIS, WITH LOSS OF HEARING, TINNITUS,
AND PECULIAR VERTIGO.
B. G., set. 52, a widow, had been healthy until twelve years
before admission, when she had a severe attack of rheumatism,
chiefly involving the knee joints. Four weeks later she be-
gan to have violent pain in the right side of her head, which
subsequently extended to the top, and then to the left side.
She suffered from these head pains, with but slight intermis-
sions, for two years, when total paralysis of the left side of
the face made its appearance, and was accompanied by loss of
hearing and by noises in the ears. Spells of giddiness of a
peculiar character came on with the paralysis. On attempting
to walk she would soon be compelled to run, and on getting
into a run, she would fall on her face, unless she could stop
herself by taking hold of some object. She felt as though
she, herself, and the floor under her were going around.
These vertiginous spells gradually grew less frequent and
severe as the patient's general health became better. She ha3
never had a discharge from the ear, but has suffered from
more or less headache ever since the facial palsy occurred.
For three months she had double vision. For six months
130 Notes of Hospital Practice.
she had some difficulty in swallowing, fluids sometimes being
regurgitated through her nose. On admission the right side
of her face and both arms and legs were found to be unaffected
by paralysis, but the left side of the face showed marked
paralysis and atrophy. The usual lines and furrows were
obliterated, and the cheek sagged downwards. No movements
could be performed by any of the muscles supplied by the
left facial nerve. Lagophthalmos was marked, the left eye-
lids remaining wide open. The lower lid was slightly ectropic.
The conjunctiva was generally somewhat injected. She had
full control of the movements of the left eye, which she could
move in any direction. A peculiar motility of this eye was
noticeable. It was almost constantly jerking or wabbling
upwards and downwards, going slightly outwards in its ascent.
Sight in this eye, when it was fixed, was good. Her nose and
mouth were drawn far to the right. She had no control what-
eve over the paralyzed muscles; she could not dilate the
nostril, raise the lip, draw upwards or outwards the angle of
the mouth, etc. She could speak distinctly and protrude the
tongue without visible deflection. The uvula pointed slightly
towards the right, and the velum hung lower on the left than
the right side. On touching it with a probe it retracted up-
wards and towards the right. Taste was generally defective,
but it could not be made out distinctly to be abolished on the
anterior part of the left half of the tongue. She complained
of dry ness of the mouth. Hearing in the left ear was entirely
gone, and she had constant noises in this ear. Smell was
defective, but no differences could be made out between the
paralyzed and healthy side. Sensation, as determined by the
sesthesiometer and the faradic battery, was slightly, but un-
doubtedly, diminished on the affected side. Both farado-con-
tractility and galvano-contractility were also much diminished.
Reflex movements could not be produced by irritating the
skin of the face. The surface temperature was carefully taken
in the middle of each cheek; it was 91.8 F. on the left or
paralyzed side, and 95.t " F. on the right. At times ene still
Nervous Diseases. 131
had spells of giddiness. On going up stairs she became
giddy, but was never troubled in this way on coming down.
Her appetite was poor; her bowels were constipated; she was
frequently troubled with nausea, particularly in the mornings.
The nausea was not accompanied by vertigo. She was nerv-
ous and irritable, and her general condition as regards strength
was not good.
The symptoms presented by this case were interesting, and
some of them unusual. They indicated an extensive lesion,
probably a rheumatic or syphilitic exudation or tumor com-
pressing the facial nerve at the base of the skull. Destruc-
tive disease of the petrous portion of the temporal bone might
also explain the case. The peculiar form of vertigo is worthy
of note. The facial nerve, in the first part of its course,
passes forward, resting on the oerebellar crus, and it might be
considered whether an involvement by the disease of this arm
of the cerebellum, or of the cerebellum itself, had not some
agency in the production of the vertigo, and the tendency tc
run and plunge forward. Auditory vertigo does not usually
take the form presented in this patient.
Tlie head symptoms -pain and vertigo were greatly bene-
fited by the use of iodide of potassium and quinine. Strych-
nia and carbonate of iron were also administered with the
effect of improving the general condition of the patient.
Massage and faradization and galvanization, both with the
continuous and the interrupted current, were persistently em-
ployed directly to the nerve-branches and muscles, but with
little benefit, as both nerve and muscle degeneration had gone
so far as to preclude much hope. Di\ C. K. Mills.
SPASM OP THE SPINAL ACCESSORY NERVE.
Dr. Wood's treatment is by means of hot irons applied to the
nape of the neck and immediately over the contracted muscles.
The heat used is intense, and is only very lightly applied, so
as not to produce a very deep eschar. Together with this
cauterization the iodide of pote^'nm is administered.
132 Notes of Hospital Practice.
SEXUAL EXHAUSTION.
When this condition is a result of masturbation, as a first
and most important step the patient is persuaded to stop the
practice at once and forever. Then the hygienic treatment is
in order. Enough exercise is taken each day to produce deci-
ded fatigue. Meat is forbidden as a general article of diet,
and the patient lives largely upon farinaceous food. A gen-
eral meat diet has been proved to throw a great strain on the
kidneys.
All kinds of exercise which irritate the genital organs are
strictly forbidden by Dr. H. C. Wood. As sleeping on the
back provokes emissions, the patient is advised to always sleep
on his side on a hard bed, with as few covers as the weather
will allow. All sexual literature and theatrical scenes are
avoided.
As regards medical treatment, bromide of potassium ia
given in doses of from 20 grains to half a drachm thrice
daily, or in the place of the bromide 5 grains of brominated
camphor are given three times a day in emulsion. Along
with this soothing treatment iron and some bitter tonic are
with propriety employed. In some instances ergot, by reliev-
ing the congestion of the spinal centres, does great good.
The treatment of sexual exhaustion from excessive venery
is about the same as that just sketched out. A specific remedy
is phosphorus. Ergot is also always used, where there is
numbness or prickling of the limbs.
In impotence, with spermatorrhoea, the following prescrip-
tion has been found to act like a charm :
R Tine, canthar gtt. yj.
Tine, ferri chlor gtt. xv-xx. M.
SiO. Thrice daily in water.
PARAPLEGIA DUE TO A SPINAL SPRAIN.
The most important indication is thought by Dr. Levis to
consist in producing a powerful counter-irritant effect along
Nervous Diseases. 133
the spine, with a view of removing, if possible, the plastic
effusion upon which the paraplegia depends. With this indi-
cation in view, the most powerful counter-irritant known,
which is the iron at a white heat, is employed. In using the
hot iron upon a patient, he is placed under the influence of an
anaesthetic and six issues are made, three upon either side of
the spine, in the lumbo-dorsal region.
There is a nice little point about the after-treatment of the
cauterized spots, which has not, as a rule, received the atten-
tion it merits. If, after the hot iron has been applied, the
parts be left exposed to the air, or even the ordinary cold
water dressing be applied, the patient will suffer a great deal
of pain. But if pure carbolic acid which has simply been
deliquesced by the application of a moderate heat, so that it
may be conveniently spread with a camel's-hair pencil be
applied to the cauterized spots, it produces such a marked
anaesthetic effect as to take away almost all the pain which
would otherwise harass and distress the patient. This is a
little point, but one which, if observed, relieves considerable
suffering. The parts are protected by the ordinary patent lint
and carbolized oil dressing, which is covered with waxed
paper, and secured in place by adhesive strips.
During the period of inflammation, in spinal lesions of this
character, the bromide of potassium is indicated ; but later on
in the affection, strychnia is the agent upon which most reli-
ance is placed.
MISCELLANEOUS.
THE INTRAVENOUS INJECTION OP MILK IN FUNCTIONAL
AND ORGANIC ANEMIAS.
A female, set. 33, was admitted to the University Hospital
in the spring of 1878, suffering from extreme anaemia and
spinal irritability, which had been induced by a series of
depressing causes, miscarriages, hemorrhages, mental strains
and nervous shocks, the latter requiring a large amount of
morphia in their management. Other forms of treatment
having been assiduously persevered in without any good effect,
it was determined to inject milk into her veins. On June
20th, Dr. Charles T. Hunter opened her right median basilic
vein and injected five fluid ounces of fresh cow's milk, the
cow being milked in an apartment adjacent to that in which
the patient lay. The immediate results of the operation were
most striking. Almost as soon as the milk entered her veins
the patient's face assumed a deep purplish color, her conjunc-
tive became injected, and she clutched at her throat. These
symptoms disappeared, however, upon lowering the funnel
and allowing the milk to flow in more slowly. In a few
minutes a very marked capillary injection appeared in the
palms of her hands, her face and the back of her neck. At
the same time two attacks of uticaria came on at intervals of
eight minutes, and were gone in five minutes after the first
appearance of the rash. Half an hour after the operation a
chill supervened, lasting fifteen minutes. Before the opera-
tion the pulse was 108. After the milk was injected it ran
up to 150, being 128 when the uticaria appeared. Two hours
and a half after the injection the temperature ran suddenly
134
Miscellaneous. 135
up to 103 F., and then fell again. The patient passed a
very comfortable night.
June 25th. No marked improvement.
June 27th. The patient was again operated upon, the same
quantity of milk being injected. Previous to the operation
20 grains of quinia were given. [This same amount of
-juinia had been administered previous to the first operation.]
No sooner had a fluid drachm of milk entered the circulation
than great capillary congestion followed, and the patient com-
plained of bursting pain in her head. A severe cramp seized
her, and in the course of fifteen minutes her menses appeared.
Again two attacks of uticaria supervened.
June 29th. The patient was much stronger.
July 17th. Milk to the amount of 6 fluid ounces was
again injected. The injection was followed by the same symp-
toms. From that date the patient's condition steadily im-
proved. She gained in color, and her nervous phenomena
disappeared entirely.
THE ASSIMILATION OF COD-LIVER OIL.
Some months ago Dr. Wm. H. Bennett instituted a series
of experiments regarding the assimilation of cod-liver oil by
the system. The stools of a number of patients, placed upon
the daily use of this article, were carefully examined, and it
was found that in the majority of cases these stools were oily,
showing that the cod-liver oil had simply passed through the
alimentary canal without absorption. Where the stools were
oily the patients appeared to have derived no benefit from the
use of the oil ; but in the few cases where the stools were not
oily, and where the oil had consequently been absorbed, the
patients had grown fat.
Quite recently Dr. Milton Miller, the medical resident,
at the Episcopal Hospital, has conducted a second series of
experiments of the same nature, and has obtained like results.
136 Notes of Hospital Practice.
SLEEPLESSNESS IN UTERINE DISORDERS.
When patients complain of nervousness or of sleeplessness*,
the bromide of potassium is given either alone or in combina-
tion. A cheap and efficient mixture is the following:
R Pulv. ferri sulph. exsic gr. xxx.
Potassii bromid.
Had. coiumbse contus ^ aa %j.
Aquae bullientis .Oj.
Steep for 24 hours and then strain.
SIG. One tablespoonful in a wineglassful -of water just before or just
after each meal.
In other cases the following is used :
R Elixir, humuli - f^j.
Elixir, ammon. valerian.
Syrupi lactucarii aa f^ss. M.
SlG. One dessertspoonful at bedtime, or during the day when needful.
Dr. -OooddL
ATROPIA AS A PREVE1STTIVE OF PY.EMIC CHILLS.
In several instances of abscess of the liver and of pyaemia,
Dr. Starr administered the I/QQ of a grain of atropia by hypo-
dermic injection, and the 1/ 60 of a grain internally, to prevent
the distressing chills consequent -upon these conditions. This
remedy acted like a charm. The effects of the dose or hypo-
dermic injection given in the morning lasted through the fol-
lowing twenty-four hours. The same' was the case with the
belladonna-bath (tr. belladon., f 3 ij ; spts. frumenti, f3ij;
aquae, f ij. SIG. To be applied to the whole surface of the
body by sponge at bedtime.)
DIGITALIS BY HYPODERMIC INJECTION.
Dr. Starr has recently been employing digitalis hypodermi-
cally with much success in cases of advanced phthisis and of
heart failure. The injections at first contained gtt. v of the
tincture of digitalis and TT[,x of water. Tlie effects being
Miscellaneous. 137
negative, the amount of the digitalis was increased to gtt. x,
with the most decided effects. The pulse fell at once from
120 to 105 in the minute. At one time as much as gtt. xv
of the digitalis were injected with great advantage.
OPHTHALMIA NEONATORUM.
A solution of nitrate of silver (f of a grain to the ounce) is
injected under the lids twice a day.
For the lids themselves the following is usually employed :
li Sodae boratis gr. xij.
Zinci sulphatig gr. j
Aquse camphore f."j.
Aquae clestillatae fjfj. M.
Sio. To be applied to the fids two or three times a day.
A plan of treatment highly recommended by Mr. Dickson,
of London, viz., the injection between the lids every half-hour
of a solution of alum (from 5 to 8 grains to the ounce), the
strength of the solution to be gradually diminished as the case
gets better, has also been tried with very gratifying results by
Dr. J. F. Meiga,
INDEX.
Abortion 97-100
Abscesses, The Hyperdistension
of 71
Acne Rosacea 37-38
Addison's Disease 41-42
Amenorrhcea 104-105
Anaemias, The Intravenous In-
jection of Milk in Functional
and Organic ..134-13*5
Anaemia and Chlorosis 90-92
Aneurism 54-55
Angina, Acute 47
" , Pseudo-Membranous..! 9-21
Aorta, Constriction of. _..43-45
Aortic Valve, Patulous, Accom-
panying Chronic Bright's Dis-
ease -...32-33
Apoplexy 116
Artli ri tis, Rheumatoid . ..33-37
Atropia as a Preventive of Pyse-
mic Chills 136
B.
Brain, Unique Case of Injury to
the 78-81
Brain, Compression of the 81-82
Brain Disease, Treatment of
Syphilitic 114-115
Breasts, Gathered 100-101
Bright's Disease, Patulous Aor-
tic Valve Accompanying
Chronic 32-33
Burn followed by Contraction of
Tissue..., ....72-73
O.
Calabar Bean in Dementia Para-
lytica 116
Cancer, Epithelial 82
Catarrh, Post-Nasal 51-52
Cautery, The Actual 114
Celluiitis, Pelvic Peritonitis and,
85-86
Cerebral Exhaustion, Treatment
of 115
Cervix Uteri, Cancer of. 106
" , Conical 107
Chills, Pysemic, Atropia as a
Preventive of. 136
Chlorosis, Anaemia and 90-92
Chorea 121
Clavicle, Fractured 65 and 81
Cod Liver Oil, The Assimilation
of 135
Collapse - 47
Constipation, Habitual with Fis-
sure of Rectum 104
Cystitis in the Female 106-107
" Mate 66-68
D.
Dementia Paralytica, Calabar
Bean in 116
Diabetes Insipidus 51
" , Saccharine 40-41
Digitalis by Hypodermic Injec-
tion 136-137
Douglas' Pouch, Hsematoma in, 87
Dropsy, Tapping in 70
Dysentery, Acute and Chronic,
48-49
140
INDEX.
Dysmenorrhcea 95
Dyspepsia 49-51
E.
Eczema, Chronic 33-37
Electricity 110-111
Elephantiasis Arabum, Nerve
Section for , 61-64
Endometrium, Fungous Granu-
lations of 108
Erysipelas 83
Eustachian Tubes, Inflammation
of 28-29
Exhaustion, Sexual 132
P.
Fever, Contagion in Scarlet 30-31
" Pleuro - Pneumonia fol-
lowing Typhoid 12-15
Fever, Puerperal 94-95
" Typhoid, Some cases of,
and their treatment 5-10
Fever, Typhoid, some interesting
points in the Diagnosis and
Prognosis of 3-5
Fever, Typhoid, the treatment
of. 10-12
Fever, Thermic 46
Fistula, Vesico- Vaginal, Closure
of Vulva for 108
Fracture below the Knee, Ex-
tension in 81
Fracture, Intracapsular 81
Frontal Bone, Rapid Recovery
from Depressed Fracture of, 71-72
Funifl, The Treatment of the 100
G.
General Notes 116
Gleet 64
Goitre 49
Gonorrhoea in the Male 73
Graves' Disease.... ... 27-28
Haemoptysis 40
Heart Disease, The Treatment
of Organic 17-19
Heart, Hypertrophy of. 43-45
Hemorrhage, Post-Partum 88-90
Hemorrhoids, External 70
Hernia, Temporarily Irreduci-
ble 77-78
Hip-joint Disease 61
I.
Influenza 55
K.
Kidneys, Albuminoid Degene-
ration of. 19-21
L.
Lumbago 52
M.
Massage and Swedish Move-
ment 113-114
Menopause, The 92-93
Metal oscopy and Metalotherapy,
111-113
Middle Ear, Inflammation of
the 28-29
Milk, Intravenous Injection of,
in Functional and Organic
Anaemias 134-135
N.
Naevus Materna 69-71
Nasal Passages, Inflammation of,
28-29
Nephritis, Acute and Chronic
Tubal 56
Nephritis, Chronic Interstitial... 56
Nipples, Sore 101-102
O.
Ophthalmia Neonatorum 1 37
Opium Habit, The 54
Ovarian Cyst, Diagnosis of 95-96
141
Ovaries, Prolapse of the 107
Ovariotomy 101
Ozena ...19-21
P.
Palsy, Iron Pullers'...^ 123-126
" Violinists' .,123-126
" Weavers' ...123-126
Paracentesis Thoracis, Indica-
tions against 15-16
Paralysis, Facial, Followed by
Secondary Spasms, -etc 126-129
Paralysis, with Loss of Hearing,
etc 129-131
Paraphimosis 84
Paraplegia due to a ..Spinal
Sprain 132-133
Patella, Fractured 60
Perimetritis 87-88
Perinseum, Laceration of the...96-97
Peritonitis and Cellulitis, Pelvis,
85-86
Peritonitis Idiopathic 21-23
Perityphlitis 42-43
Phthisis, Laryngeal 52-54
" , Nigtf Sweats in 29
Placenta Praevia 102
Pneumonia . 16-17
Psoriasis, Cl.ronic ., 42
Pregnancy, The Diagnosis of, 93-94
" , The Vomiting of.... 87
Prostatorrhoea with Stricture...68-69
B.
Rectum, Fissure of .the, with
Habitual Constipation 104
Recurrent Laryngeal Nerve, Pa-
ralysis of 122
Rheumatism, Acute and Chronic,
47-48
S.
Sciatica 38-40
Shock, Surgical 65
Sore Throat, Syphilitic 76-77
Spine, Curvature of the 65
Spinal Disease, Three Interest-
ing cases of..... 116-121
Spinal Accessory Nerve, Spasm
of the. 131
Spinal Exhaustion, The Treat-
ment of. .. 115
Spinal Sclerosis, The Treatment
of. 115
Spinal Sprain, Paraplegia due to
a 132-133
Sprains ^ 73
Stomach, Dilatatiqn of the 37
" , Ulcer of the 51
Stricture.... 74-76
" with Prostatorrhoea....68-69
Swedish Movements, Massage
and. ..113-114
Syphilis, Diagnosis of Congeni-
:tal 102-104
T.
Tetanus ... 123
Tinea Favosa 38
Toe-Nail, Ingrowing 82-83
Tonsillitis, Acute 46
U.
Ulcers 65
.Uraemia 56
Urethra, Foreign Body in 57-59
" , Caruncle of 105-106
Uterine Disease, Sleeplessness
in 136
Uterus, Anteflexion of. 86-87
V.
^Vaginiemus 109
Vaginitis 108
Vertigo, Gastric 41
Vomiting, Two Interesting Cases
of 23-27
Vulva, Closure of the, for Vesi-
co-Vaginal Fistula 108
NOTES
OF
HOSPITAL PRACTICE
PART II.
NEW YORK HOSPITALS.
EDITED BY
SAMUEL M. MILLER, M. D,
PHILADELPHIA, PA.
SAMUKL M. MILLER, M. D., Publisher.
1880.
GENERAL DISEASES.
ACUTE PNEUMONIA.
Dr. Alonzo Clark has not lost a fondness for the lancet in
pneumonia. He is accustomed to use cups after scarification,
taking three, four, or five ounces from the affected side. He
does not place any confidence in the calomel treatment, or in
Laenuec's treatment by tartar emetic, but is satisfied, when the
temperature rises to 105 or 106, that the safest and most
efficient medicine is quinia, given in doses of 10 grains thrice
daily. The application of cold to the surface of the body is
thought to be disastrous. Dr. Clark does not allow any ice
to be applied to any patient of his who has pneumonia. He,
however, regards sponging with cold water as admissible, and
is in favor of the employment of a bath at a temperature 20
below that of the body. His objection to veratrum viride is
that, when it is given with any freedom, it is very apt to lead
to collapse ; aconite, he thinks, safer. He regards the alco-
holics as utterly useless in the treatment of this affection.
Ten years ago, at Bellevue Hospital, pneumonia was quite
uniformly treated with carbonate of ammonium, internally,
and an oil-silk jacket, externally. The carbonate was given
in doses of gr. v every three hours, or sometimes gr. x thrice
daily. The muriate was occasionally substituted. Gradually,
quinia came to be combined with the ammonium, while to-
day, quinia has entirely taken its place in many wards. The
quinia is given in doses of gr. x thrice daily, increased or
diminished according to the fever. The oil-cloth jacket is
still continued, and, if there is much pain in the side, a coat
of iodine is ordered. This, with an absolutely recumbent
(1)
2 Notes of Hospital Practice.
posture, is all that is enjoined in many cases. Aconite has
been used in five cases, of which one died. It is given in
doses of Ity ever y hour, until some effect of the drug, either
in the relief of dyspnoea or fever, or the production of sweat-
ing, is brought about.
In 44 cases, quinine was used with good results. The
method of administration is varied. Besides the routine men-
tioned, it is given gr. j every hour, or gr. v every four hours,
or often gr. xl or gr. 1, in one dose, then discontinuing it for
a day or more. The antipyretic effect of quinine has not
been sufficiently marked to make it clear which is the best
way. Cold sponging has been employed with quinine. Of
seven cases so treated, three died. The gradually-cooled bath
has been used, and was at once given up.
Many cases that have been admitted into the hospital have
had a record like the following : The patient is a tolerably
strong man, in the third day of the fever. He has a tem-
perature of 104, respiration 50. His pulse is very good, and
he feels pretty comfortable. He is given milk and eggs, and
gr. xv of quinine. This is in the morning. In the afternoon
he is weaker, his face is a little blue, he breathes faster. On
listening to the lungs, moist rales, fine and coarse, are heard.
He is beginning to have oedema. He is at once dry-cupped
for fifteen or twenty minutes, during which time 150 cups are
put on. The oedema has now disappeared. He is ordered
fn x of tr. digitalis every three hours, and f ss of whiskey
every two hours, with milk and eggs. He continues better
for some hours. Towards evening the oedema again shows
itself. He is again cupped, and gr. x ammon. carb. is ordered
every two hours, alternating with the whiskey. Again the
oedema clears up. In addition, a can of oxygen is ordered
for the night, and the patient inhales it for 15 minutes in
every hour. This relieves his dyspnoea. But, towards morn-
ing, the cyanosis and oedema again appear. The cups are
applied again, and the whiskey ordered, ss every hour, alter-
nating with the ammonia, gr. x every hour. By these mea-
General Diseases. 3
sures, he is carried through the night, and in the morning is
easier. Nourishment in the form of milk is still kept up.
He is not allowed to sleep continuously, for, during sleep, the
oedema comes on. By such fighting as this -the greatest reli-
ance being placed on whiskey, milk, and dry cups a patient
is occasionally brought through. If, on the following day,
he is still worse, the resources in the way of stimulants are
not exhausted. Other forms of ammonia are used. Hypo-
dermic injections of camphor dissolved in sweet oil, are given
every three hours, in 4-grain doses. If the patient has
persistent oedema and a full pulse, venesection is tried, and is
invaluable when digitalis and cups no longer avail. The
oxygen cannot be pushed too much, as it causes unconscious-
ness.
Hypodermic injections of ether to the amount of 1 or
2 drachms, sometimes bring up the pulse. Teaspoonful
doses of champagne every five minutes, will help to tide a
crisis. There is a limit to stimulation, of course. When
| ss of whiskey every half hour has no effect, the patient
will die.
It will be seen that no new or specific treatment can be
deduced from these cases. It has become a firmly-rooted
belief that quinine is a good thing to give, and in those so
treated, the mortality has been somewhat diminished. The
class of patients is not one upon which cardiac sedatives can
be fairly tried.
Dr. Austin Flint treats pneumonia by rest in bed and the
administration of half an ounce of whiskey every two hours,
with milk for nourishment. When the action of the heart is
iveak and irregular, digitalis is administered in doses of H^xx
of the tincture three times a day.
EMPYEMA.
In all cases of empyema Dr. Alonzo Clark expects to punc-
ture several times. His practice is to incise the skin, plunge
4 Notes of Hospital Practice.
in a trocar and canula, and after withdrawing these instru-
ments, insert into the opening thus made a linen tent, which
he fastens by its free ends to the chest by means of adhesive
strips. This teat is removed every day or two to allow the
pus to run out. Dr. Clark is also very partial to Dr. Wy man's
method, as practiced by Dr. Bowditch, of Boston. This con-
sists in the use of the exhausting pump, and for this purpose
he likes the ordinary stomach pump. He uses an extremely
small trocar, and a common exploring needle, which he regards
as a good instrument for this purpose, or better still, the aspira-
tor with a fine trocar. Before introducing the instrument he
considers it well to benumb the part by firm pressure with the
finger. In these cases he has not found it necessary to use the
scalpel as when a large trocar is used. After the trocar has
been withdrawn the canula is pressed in some distance, as it
will not hurt the lung if it touches it The piston is worked
slowly. As the opening thus made is small it closes itself to
the exclusion of air asoon as the canula is withdrawn. Dr.
Clarks regards this last method as peculiarly desirable before
it has been ascertained that the effusion is purulent by a pre-
vious operation. When it is known that the cavity contains
pus, Dr. Clark does not pretend to choose between the two
methods. He continues to draw off fluid until oppression is
felt at the %tern\vm, and guards against drawing off too much
for fear of making a vacuum, too great for the comfort of the
patient. When the operation is performed in front it is done
between the sixth and seventh rib, to avoid wounding the
diaphragm. On the side he selects a spot between the seventh
and eighth rib, and in the back between the eighth and ninth
rib. He thinks that iodine injections for the prevention of
further effusion of pus are attended with more harm than
good. If injections of any sort are to be used he prefers
simple warm water. Tonics he regards as more or less ser-
viceable, and this he thinks is about all that can be done in
the way of treatment. Even under the best management he
expects half of these patients to die.
General Diseases. 5
DIPHTHERIA.
Dr. C. E. BiiliugtoD recommends the following prescrip-
tions :
No. 1. Iron and Glycerine Mixture.
R Tinct. ferri chloridi ~.~ fj.
Glycerinae,
Aquae. ~ aa f^j. M.
Sio. A teaspoonful of this and f No. 2, alternately, every half hour
through the day.
No. 2. -Chlorate of Pota&swm Mixture.
R Potassii chlorat ~. Jss.
Glycerinse. ~ fsss.
Aquae calcis. ......~ f^ ijss. M.
Sio. A teaspoonful of .this and of No. 1, alternately, every half hour
through the day.
No. 8. Spraiy Misctwe.
R Acid, carbol ~. TT^v.
Aquae calcis ~ f^ vj. M.
Sio. To be used with a small haad atomizer.
The patient is allowed to sleep for an hour or two at a time
at night. When awake, doses ef No. 1 and 2 are alternated
every half hour. The throat is sprayed with No. 3 for several
minutes at a time, whenever Nos. 1 and 2 are given. In
spraying, the mouth is opened widely.
Where there is nasal implication the nose is thoroughly
syringed out with warm or tepid salt-water, once, twice or
three times a day. This syringing is done with the patient's
head inclined forward, a two-ounce hard-rubber ear syringe is
used.
Dr. Billington never applies any brush or swab to the
throat. He sometimes throws a drachm of No. 1, with a
syringe, directly against the affected surface in the throat.
He does not give quinia or any other unpleasant medicine to
children. He does not give alcoholic stimulants except where
6 Notes of Hospital Practice.
a child, who cannot be induced to take other nourishment, will
take weak milk-punch or egg-nog.
The patient is nourished with an abundance of cold milk,
given frequently, to which a little lime-water is often advan-
tageously added. When the stage of extreme exhaustion has
been reached in bad cases the juice squeezed from beek-steak
is given.
ASTHMA.
Among the means by which asthmatic attacks are treated
by Dr. Clark, is the inhalation of the smoke of dry stramonium
leaves, or else he orders a piece of bibulous paper to be dip-
ped into a solution of the nitrate of potassium until it becomes
pretty well filled with nitre. This paper is then dried and a
small piece of it is burnt, and the sufferer inhales the fumes.
The most efficacious remedy for allaying the spasms, of which
he knows, is the inhalation of the nitrite of amyl. This drug
will stop the individual attacks, but will not cure the disease.
Dr. Clark recognizes but one radical cure for asthma, and
that is the iodide of potassium. One-half of his patients are
cured by it.
SUB- ACUTE PLEURISY.
Dr. Clark aims, on the one hand, at subduing the inflamma-
tion, and on the other, at promoting absorption of the fluid.
Bleeding from the arm he regards unnecessary, but when
he is called at an early stage, which is seldom the case, he
advises the use of cups, and repeats them as often as necessary.
He thinks that cups have great influence over recent inflamma-
tions, but that they do little good in sub-acute and chronic
inflammations. As in other sub-acute inflammations, blisters
are applied, and in doing this he selects three spots, one being
placed on a new spot as the last has healed. He scarcely ever
finds that more than three are required. Among active
General Diseases. 7
diuretics, he prefers potassii iodidi, gr. xxx per day. If this
does not subserve, he tries the following :
& Potas. acet.,
Inf. digitalis aa f^ij-iv.
Each day.
Or:
R Pulv. dig.,
Pulv. sallse mer.,
Hydrarg. chlo. rait. aa gr. z. M.
Et ft. pil. No. x.
Sio. One pill thrice daily.
He uses this until the effect of the mercury is produced,
and then tries potass, iod. again. In some cases he finds that
mild counter-irritants, such as the ammoniacal liniment, an-
swer, as in nervous women, but, as a rule, he does not trust
to these. Purgatives and vapor-baths, he sometimes finds
useful. This treatment he thinks will suffice in ordinary sub-
acute pleurisy, but when all these measures fail, he claims that
we have but two resources to do nothing or to use the trocar.
Some physicians advise the early use of the trocar, but from
fear of changing the serous effusion to pus, he does not like
the practice. In some cases he is forced to use the trocar, but
always uses medical means beforehand, if the patient is not
rapidly sinking.
CHRONIC SUPPURATIVE INFLAMMATION OF THE MIDDLE
EAR.
Dr. O. D. Pomeroy regards cleanliness as the chief item of
treatment. He does not approve of the syringe as a means of
cleansing the ear, but makes use of cotton wool. In some
cases, however, where the amount of the discharge is very
great he is compelled to employ the syringe. After the ear
has been cleansed he uses astringents in the shape of nitrate
of silver. To apply this astringent properly he makes use of
a dropping tube which consistsof a hard-rubber catheter with
8 Notes of Hospital Practice.
a soft rubber thimble upon its ring extremity. From three
to six drops of the astringent solution are thrown into the ear
with some little violence, then drawn out, and the process
repeated several times while the dropping tube is still inserted
in the ear. If the perforation in the drum membrane is small,
and if it is evident that there are extensive purulent processes
going on in the tympanum, Dr. Pomeroy does not hesitate to
make an incision in the membrane, so that the astringent can
be effectively introduced. The solution of nitrate of silver
used has a strength ranging from 10 grains to the ounce, all
the way to 480 grains to the ounce. This saturated solution
has been employed upon several occasions without causing any
pain or discomfort. The rule adopted is that the solution
used should never be strong enough to give rise to pain.
Where there is evidence of purulent inflammation of the
tympanic cavity without perforation, a strong solution painted
upon the drum membrane has frequently been found to arrest
the purulent process.
With regard to the use of other astringents the objection
urged against alum is that it forms alum-curds which act as
foreign bodies in the tympanic cavity. Acetate of lead, has
been occasionally employed by Dr. Pomeroy in solutions of
from 2 to 10 grains to the ounce. Carbolic acid has the
additional value of being a disinfectant. The solutions em-
ployed vary in strength from 2 to 4 grains to the ounce.
Where there is a relaxed condition of the lining membrane
of the tympanum the cavity is packed as full as possible with
absorbent cotton.
Dr. Pomeroy does not believe in artificial drum membranes,
He recommends his patients to wear cotton in their ears
until cured. The cotton is placed loosely in the ear and
removed as often as it becomes in the least moist.
Granulations or polypi are treated by removing them with
the forceps. Small nasal forceps have been found to answer
tfiis purpose very well. A speculum is avoided, if possible,
but may be used to good advantage where the polypus is
Crenera/ Diseases. 9
small. Hemorrhage from the root of the polypus is con-
trolled by means of nitrate of silver or liquor ferri persul-
phatis.
After removing the polyp the completion of the cure ie
effected by means of cauterization with nitrate of silver. For
this purpose a saturated solution of the crystals is employed.
The method is to take a fine probe, wind the tip* with a piece
of cotton, dip it in the solution, remove the excess by wiping
on blotting paper, and then apply it to every remaining por-
tion of the polypus until it is completely whitened. Th
strongest nitric acid is sometimes used instead of the nitrate of
silver, but is applied more carefully. In some instances burnt
alum and iodiform have been of valuable assistance in remov-
ing granulations and bases of polypi. Sequestra are removed
with the forceps or chopped away by means of a dentist's drilL
ACUTE PLEURISY.
This disease, according to Dr. Clark, is, by common consent,
better controlled by the lancet tlian any other serous inflam-
mation. He applies cups with scarification, to the affected
side, and repeats them two or three times, after proper inter-
vals. When the pain has subsided, blisters are applied, to
overcome whatever inflammation remains. The treatment,
then, adopted by him is decidedly antiphlogistic, so as to pre-
vent abundant effusion. He believes that there is no occasion
for diuretics. He makes use of diaphoretics in the latter
stages. Fomentations of warm water, and the like, are some-
times applied to the affected side. Not much constitutional
treatment is required. Dr. Clark claims that the membrane,
in cases which i^over, is left and is organized, and that con-
traction of side and shortness of breath will occur in every
form of pleurisy, but that this does not take place until sev-
eral weeks after the attack, and continues for three or four
years, during which time the membrane becomes absorbed.
10 Notes of Hospital Practice.
VOMITING IN PHTHISIS.
When caused by pressure of the enlarged bronchial glands
upon the par vagum, in the early stage of phthisis, it is
arrested, in the wards of the Roosevelt Hospital, by the
application of dry cups between the scapulae. Carbolic acid
is prescribed; to remove the vomiting consequent upon the
offensive taste and odor of the expectoration.
DIARRHOEA OF PHTHISIS.
When this symptom is present, the patients in Roosevelt
Hospital are fed upon milk boiled with mutton suet until it
is as thick as cream. A piece of suet is put in a bag and
boiled in milk until the requisite consistency is obtained.
The following pill has been used with excellent results, in
these cases :
H Kesin. terebinth gr. iij.
Argenti nitrat.,
Opii aa gr. J M.
Sio. One pill when needed.
APHTHA OF PHTHISIS.
The following mixture is used at the Roosevelt Hospital.
The patient may either apply it with a brush or rinse his
mouth with it :
R Quinae sulph gr. j.
Olei piperis nigris gtt. j.
Aquae f|j. M.
SORE THROAT OF PHTHISIS.
For the relief of this condition, salt-water and oil of black
pepper, in spray, are used at the Roosevelt Hospital. The
solution of salt is no stronger than that made by adding a
General Diseases. 11
teaspoonful of common salt to a pint of water. The oil of
black pepper is added, in the proportion of 1 drop to the
ounce.
JAUNDICE.
Dr. Clark recommends the free use of soda, and regards it
as a better cholagogue than mercury. The form of soda pre-
scribed is the carbonate, in 3 ss doses, thrice daily. It is
sometimes taken to advantage in Vichy water. As a tonic,
in this condition, he prefers the proto-carbonate of iron, or
the chocolate iron lozenges.
SPORADIC PERITONITIS.
Dr. Clark believes that under proper treatment a consider-
able number will recover, but that whatever is done must be
done with energy, as the natural dilution of the disease is
"four days" Blood-letting, both general and local, he prac-
tices to a considerable extent in the treatment of this disease.
Dr. Armstrong proposed blood-letting, followed by a full
dose of opium, as the latter perpetuated the effect of the bleed-
ing ; but while he looked upon both as necessary, if he could
have but one, he preferred the opium. Drs. Palmer and
Child, of Vermont, treated their patients by the Armstrong
method, in 1844, with success. When Dr. Clark first adopted
this mode of treatment, eight recovered, the ninth died. His
rule is to give as much opium as the patient can take without
being narcotized, beginning with gr. ij iv every two hours,
until the symptoms of narcosis begin to show. In the case of
a hospital patient, gr. iv were given, and the dose increased
gr. j every hour until a gr. xii dose was taken. One objection
to this plan of treatment, according to Dr. Clark, is, that it
requires the attention of the physician, who should always ad-
minister the opium himself. It is not important which prepa-
ration of opium is used, but it is important that the same
12 Notes of Hospital Practice.
should be used from beginning to end. If pills are used they
are freshly made up every twelve hours. Opium is given by
its effects and not by quantity ; these effects are sensible con-
traction of the pupils, marked reduction in the frequency of
respiration, diminished frequency of pulse, gentle perspiration
of skin, itching of the mucous membrane of the nose, and easy
but very much protracted sleep, from which the patient can
be easily aroused. The pain first disappears. Tympanites
continues until inflammation is subdued. The bowels are let
atone for one week longer, as they will move when inflamma-
tion subsides. The influence of opium is kept up until peri-
staltic action is re-established. The dose is then diminished,
and when a spontaneous movement occurs, it is suspended
altogether. A full dose is required at night to produce sleep.
Dr. Clark has seen peritonitis from perforation cured by
opium. No other mode of treatment has been successful in
his hands. Strong coffee and the cold effusions are used by
him as antidotes in poisoning from opium. With a fair
amount of caution and these two antidotes, he has not often
lost a patient. He does not know of a single death produced
by opium in this disease.
TREATMENT OF THE PAINS OF LOCOMOTOR ATAXIA.
A male patient in Bellevue Hospital, set. 45, had locomotor
ataxia, and suffered from excruciating pains in his limbs. He
had no double vision, but had slight nystagmus. There was
marked delay in communication of sensation to the brain
from the feet, five or six seconds passing after the foot had
been pricked before the sensation was experienced. There
was also persistent sensation, the pricking being felt for some
time after it had been done. There was also inability to locate
impressions correctly. He had not had any trouble with his
bowels or bladder, and his sexual desire and capacity were
unimpaired. There was no tendon reflex.
By the pains, he could predict accurately concerning the
General Diseases. 13
weather. For the relief of the fulminating pains, he had
resorted to the actual cautery, a variety of remedies among
them gelsemium, which relieved him for a time and hypo-
dermic injections of morphia. The hypodermic injections
impaired his nutrition and produced delirium. All remedies
used were discontinued, and for them the bisulphide of carbon
was substituted, and, applied to the spine, gave, as the patient
claimed, complete relief from all pain.
LOBULAR PNEUMONIA.
This condition, Dr. Clark treats by means of warm baths,
the oiled-silk jacket, and those medicines which produce free
diaphoresis.
GANGRENE OF THE LUNGS.
Dr. Clark's treatment of gangrene of the lungs is altogether
sustaining, consisting of sustaining foods and sustaining medi-
cines. The alcoholics are administered carefully, according
to the state of the pulse. Quinia is given in 8 or 10-grain
doses, thrice daily.
MULTIPLE ABSCESS OP THE LUNGS.
The treatment pursued is sustaining all the way through,
and, as there is certain to be hectic fever, Dr. Clark has found
quinia to be of the greatest service.
CHRONIC PNEUMONIA.
The treatment here, again, is sustaining to a high degree.
Counter-irritation is produced by means of iodine applied to
the affected side of the chest. Some three or four spots are
chosen, and each spot is painted about three times a day.
The patient is, at the same time, encouraged to eat all the
14 Notes of Hospital Practice.
food he can digest. Tonics are the medicines upon which Dr
Clark places chief reliance.
THE RHEUMATISM OP PHTHISIS.
The Roosevelt patients are placed upon :
K Potassii iodid 3J.
Fl. ex. conii giij.
Tr. opii camph f^ ij.
Aq. aurant. flor f^iv.
Aquse f 3 iv. M.
SIG. A teaspoonful thrice daily.
HAEMOPTYSIS
Has been arrested at the Roosevelt Hospital by gtt. xl of fl.
ex. ergot, taken every three hours.
ACUTE DYSENTERY.
The first indication, according to Dr. Austin Flint, consists
in a complete evacuation of the bowels, provided that this
effect has not already been accomplished by a spontaneous
prodromic diarrhoea. Castor oil is the remedy which he gen-
erally employs to meet this indication. He sometimes, how-
ever, prescribes salines. Then the inflamed intestines are kept
perfectly quiet by the use of opium. Of the three different
modes of administering opium he prefers that by enema.
When the alimentary canal becomes again more or less loaded,
the oil or salines are repeated.
In a certain number of cases he has employed the new treat-
ment by ipecac, administering from 25 to 30 grains of the
powder every eight or ten hours.
The diet employed consists in those articles of food which
are as completely digestible as possible. The tenesmus is
General Diseases. 15
relieved by cold water and ice applied to the rectum, or by
warm, soothing applications over the abdomen.
EPIDEMIC DYSENTERY.
Purgatives are here avoided. The chief reliance is placed
upon opium. It is administered early and persistently, and
to the extent of absolutely quieting the intestines, but at the
.same time avoiding the risk of narcotism. Astringents are
administered when they are well tolerated by the stomach, but
they are never allowed to take the place of the opium. Alco-
hol is given in large quantities. In a word, the persistent use
of alcohol and opium is regarded by Dr. Flint as the most
essential feature of the treatment of epidemic dysentery.
CHRONIC DYSENTERY.
Dr. Flint places more confidence in bismuth, given in large
and regular doses, than in either the nitrate of silver OB sul-
phate of copper. He rarely gives less than 3 j. His usual
dose is from 3 ss to 3 ij. His patients are sustained, by tonic
remedies and a nutritious diet. A change of climate he regards
as a most important element in the management of the disease.
A uniformly cold and dry atmosphere has been found by him
to be that best suited to these cases.
SUBACUTE ENTERITIS.
The intestines are emptied by a purgative and then kept
quiet by moderate doses of opium. Dr. Flint sees that the
diet is carefully regulated.
CHRONIC DIARRHfEA IN ADULTS.
If the lesion is situated: in the large intestine, and the irri-
tability of the large intestine, is kept up by the presence of
16 Notes of Hospital Practice.
food in the stomach, the treatment pursued at Bellevue Hos-
pital consists in not irritating the stomach, and in thereby
avoiding the exciting cause of the discharges. With this ob-
ject in view, the patient is put upon a milk diet. In most
cases, the milk does not irritate the stomach. A certain por-
tion of the casein is digested in the stomach, and the remain-
der is digested in the small intestine. Again, as the result of
experience, it is known that chronic inflammation of the upper
part of the large intestine is frequently best treated by rest,
and a diet consisting principally of fat, in the form of either
cream or cod-liver oil. By placing a patient on a milk diet,
both indications are fulfilled. The real difficulty encountered
in treating such cases is to change from the milk to some other
diet, when a change became desirable or necessary. While
they adhere rigidly to a milk diet, it is cured; but as soon as
they return to ordinary food, the diarrhoaa returns.
If complete control can be had of a patient, permanent cure
can be accomplished in many cases by introducing the ordi^
nary diet very gradually. First, stopping the milk entirely,
not continuing it with other articles of food. Then very care-
fully regulating the quantity and quality of the food which the
patient is to take. The first article used to the best advantage
is meat beef or mutton finely cut and taken in small quan-
tities at a time ; and to this, perhaps, a small quantity of toast
and tea, or an egg, is added three times a day. After a few
days, perhaps, rice is added; and so, adding the most easily
digested articles, the patient is gradually changed from one
diet to another. If the diarrhrea returns, the patient is at
once put back on a milk diet. The gradual transfer to the
ordinary diet is sometimes aided by certain drugs. The min-
eral acids and preparations containing strychnia have been
found to be the best that can be employed, taken with the
meals. The following is often used :
R Tr. nucis vom gtt. xx.
Acid, nitro-muriatic. dil.... gtt. xx. M.
SlG. Dilute well with water, and take three times a day, with mea^t;
General Diseases. 17
In this way these cases are not only temporarily, but per-
manently cured.
THE INTRAVENOUS INJECTION OF AMMONIA.
Dr. Gaspur Griswold claims that the intravenous injection
of ammonia is a prompt and powerful means of stimulation,
acting efficiently in cases where other measures are of no avail,
and that no bad effects follow its employment. He employs,
for this purpose, a solution of aqua ammonia (equal parts of
aqua-ammonia and water.) He does not perform intravenous
injection through the skin, but, dissecting down upon the vein
and exposing it, he then introduces the needle until the point
is felt free in the interior of the vessel.
OPHTHALMIA NEONATORUM.
Dr. Knapp does not think it necessary to apply any caustic,
If any is employed, he never uses a stronger solution of the
nitrate of silver than 3 grains to the ounce. He believes in
the great importance of cold applications. These application?
are made night and day, and great care is taken to open the
eyelids and carefully wash away the secretions.. This is done
every half hour. When there is proliferation of the mucous
membrane, the nitrate of silver is the proper remedy.
ACUTE PRIMARY OTORRHO3A.
Dr. H. Knapp lays great stress upon the necessity for rest,
in the treatment of this disease. His local treatment consists
in injections of warm water into the ear; leeches behind the
ear; inflation of the drum at first, cautiously, through the
catheter, then according to Politzer's method ; astringent gar-
gles; steaming of the ear; paracentesis of the drum; opening
of the mastoid process; cleansing of the ear by syringing and
wiping with u dentist's cotton-holder; the use of astringent
18 Notes of Hospital Practice.
injections into the ear, suited, in strength, to the copiousness
of the discharge and the proliferation of the mucous mem-
brane.
RECTAL ALIMENTATION.
Dr. A. H. Smith reaches the following conclusions:
1. That defibrinated blood is admirably adapted to sustain-
ing nutrition by rectal alimentation.
2. That from 1 to 6 ounces can be retained, and that fre-
quently a larger quantity can be used without very much trace
of blood in the fascal evacuations.
3. That in about one-third of the cases, it produces more or
less constipation.
4. That in a small proportion of cases, constipation persists
and necessitates the discontinuance of the blood.
5. That in a small percentage of cases, irritability of the
bowels attends its protracted use.
6. That it is only an aid to stomach alimentatio'n.
7. That its use is indicated in cases in which asthenia is
developed by disease not involving the large intestines.
8. That in unfavorable cases it is capable of giving a favor-
able impulse to nutrition not obtainable from other sources.
9. That its use is entirely unattended by danger.
MITRAL AND AORTIC REGURGITATION.
Dr. Alfred Loomis gets rid of the pulmonary congestion
by the application of dry cups. To improve the nutrition
and stimulate the flagging heart he gives iron and digitalis in
combination. Digitalin he sometimes finds to be the more
efficient preparation of the latter drug. The dose is from
VlOO to 1 /60 f a g ra i n twice daily. Absolute freedom from
mental excitement and from over-exertion is insisted upon.
The diet allowed is principally albuminous. All stimulus is
avoided. To relieve the portal circulation an occasional
General Diseases. 19
drastic purge is given calomel being the drug generally em-
ployed.
MORPHIA VOMITING OPIUM POISONINO.
Dr. Montrose A. Fallen has derived very excellent results
from the hypodermic injection of from 30 to 40 minims of the
fluid extract of coffee into the epigastrium.
ACCUMULATIONS IN THE EABS.
Dr. Samuel Sexton has found syringing with a suitable in-
strument to be the best means for removing these accumula-
tions, but he thinks that in cautious hands the curette and
forceps are often of service. The water used in the syringe
is as warm as the patient can bear. The syringe, when filled,
is held in the right hand, while the operator pulls the auricle
upward, backward and outward with the left hand, thus freely
exposing the opening of the meatus. When through syring-
ing, the meatus is dried with absorbent cotton and a firm
pledget of wool is worn in the ear for a time.
EMESIS.
Excellent results have been obtained at the Presbyterian
Hospital, from the employment of faradization in these cases,
one electrode being placed in the right auriculo-maxillary
fossa, and the other being rubbed over the stomach for several
minutes.
ACUTE RHEUMATISM.
Dr. Wrn. H. Thomson uses this prescription:
R Sol. acid, salicyl. (gr.xl-fgj) f^ q.
Tinct. gaultherise f^j.
Aquse fjiv. M.
Sio. A tablespoonful.
20 Notes of Hospital Practice.
CIRRHOSIS OF THE LIVER.
Dr. Thomson orders gr. xx of the iodide of potassium thrice
daily and half of the following mixture in the morning :
R Magnes. sulph gss.
Ferri sulph gr. viii.
Acid, sulph. dil f^j.
Aquae.... q. s. ad f% iv. M.
In some cases a pill with the following constituents has had
good effects.
R Belladon gr. vj.
Ex. nuc. vom g. jss.
Ex. colocynth gr. xij.
Aloes Socot gr. vj. M.
Et. in pil., No. vj. div.
Sio. One thrice daily.
URJEMIA.
Jaborandi has been found at Bellevue Hospital to be a very
effective substitute for the old hot-air bath, acting more quickly
and surely. It is given hypodermically in the shape of drachm
doses of the fluid extract. This dose is repeated every other
day.
CHRONIC NEPRHITIS.
Cases of this disease have been treated very successfully at
Bellevue Hospital with jaborandi. The dose is a drachm of
the fluid extract given every other morning, the patient being
kept in bed until dinner-time, when the sweating is over. It-
has been found better not to give it at night, as the bed clothes
become saturated with perspiration and sleep is disturbed and
uncomfortable.
BRONCHO-PNEUMONIA.
Dr. Wm. H. Thomson puts his patients upon a milk diet,
General Diseases. 21
with an allowance of f f iij of whiskey a day, and prescribes
the following:
R Ammon. carb.... gr. Ixxx.
Mucilag.,
Aquae . ... ia fgj. M.
SIG. A tablespoonful thrice daily.
This mixture is alternated with one containing compound
*yrup of squill, wine of ipecacuhana, and sulphate of morphia.
ACNE BOSACEA.
The pustules are all opened by means of a wide and reason-
ably deep incision. The papules are then treated in the same
manner, being cut until they bleed quite freely. Among the
methods of removing the congestion, recommended by Dr. H.
G. Piffard, are (1) poulticing; (2) holding the face in hot
water [this is accomplished as follows; The patient takes a
basin of hot water, immerses his face, withdraws it and
breathes, then immerses it again, and so on] (3) covering the
face with pieces of muslin kept constantly wet with water as
hot as can be borne. If there is much congestion of the skin,
where it is not invaded by the pustules and papules, little
scarififtitions are made wherever it is most marked. Infiltra-
tion is reduced by the use of alkaline applications. The face
is thoroughly rubbed three or four times a week with green
soap. The red color and polished appearance of the skin fol-
lowing the use of the soap is most readily removed by the
use of sulphur.
The following is the combination employed :
R Lae. sulphw,
Glycerine,
Rose water,
Bay rum , la q. s.
When varicose veins are present, they are -destroyed either
22 Notes of Hospital Practice.
by dividing them crosswise, or, still better, by dividing them
lengthwise, throughout their entire extent, with a thin, sharp
knife, and then rubbing a small amount of the persulphate of
iron into them. In some cases, they are obliterated by means
of a white-hot needle. The marked hypertrophy of the skin
present later on in the course of the disease, is treated by the
constant galvanic current, applied directly through the nose.
When the thickening is excessive, the use of red-hot needles,
or the excision of portions of the integument, becomes neces-
sary.
CROUPOUS PHARYNGITIS.
Dr. Thomson prescribes a milk diet and fiv of whiskey
a day, with the following as a gargle :
R Sol. brominii, (^j-f^ij)
Glycerinse
Aquse .............................................. q. s. ad f^ iv. M.
. TYPHOID FEVER.
Dr. Alonzo Clark believes that a case of typhoid fever, of
average severity, needs no medication except for the relief of
symptoms.
Diarrhoea he manages by the following :
R Bismuth, subnit /. 3J.
Morphise sulph g r - j- M-
Et in chart. No. xii div.
Sio. One to four a day.
Other astringents which he has found to be of service are
tr. kino, tr. catechu, and decoction of blackberry root.
Cough, when it is the result of a catarrh, is treated either
by the comp. tr. of benzoin, in 10-drop doses every three or
hours, or by means of the following combination ;
General Diseases. 23
ft Mist, guaici f 3 j~ f 3 ^
Tr. balsam, tolu gtt. vj-x. M.
Sio. Every two to four hours.
Occasionally, good has been accomplished by the inhalation
of the vapor of warm water for an hour or two every day.
Restlessness is soothed by sponging the surface of the oody
with warm or cold water. In some cases, a Dover's powder
is required.
When the temperature of the body runs very high, quinia is
given in decided doses, or coid water is employed. In young
persons, Dr. Clark finds the cold bath the most convenient
and efficient means of reducing temperature. The tempera-
ture of the bath used is just 10 below the temperature of
the patient's body. The patient is allowed to remain in the
bath for 20 minutes. If the temperature rises again, another
bath is given.
Hemorrhage from the bowels is controlled, if possible, by
absolute rest and doses of the fluid extract of ergot.
In perforation of the bowels, the patient is placed thoroughly
under the influence of opium.
Regarding diet, Dr. Clark believes in the steady and perse-
vering administration of such food as can be absorbed by the
stomach. Milk, beef tea, raw eggs beaten up with water and
made of such consistency that they can be eaten with a spoon,
and expressed beef-juice, are all of value. Where one disa-
grees, another is substituted. The expressed juice of beef is
obtained by cooking a piece of steak so as just to crust the
surfaces, and then squeezing out the juice with a lemon-
squeezer. As the disease advances, the food administered is
more and more sustaining. When the stomach fails to retain
(bod, nutritious enemata are employed.
Dr. Clark considers plenty of fresh air as of prime import-
ance to typhoid fever patients. He always insists that a wiu-
dow on the side of the room opposite the patient, be dropped
a certain distance from the top, even in the winter season, and
24 Notes of Hospital Practice.
that the patient is protected from the draft by the use of a
screen.
Bed Sores. Nothing has been found so effectual for their
prevention and treatment as a water-bed. Where this cannot
ta obtained, the best substitute is the padded ring, or a rubber
ring filled with air.
Tympanites. Cold compresses are applied to the abdomen,
and covered with oiled silk. Where this fails, a stimulating
injection is given, consisting of Oss of a solution composed
of Labarraque's solution, 1 part, and water, 16 parts. In
other cases, from 8 to 10 drops of the spirits of turpentine
are given in mucilage.
Abscesses are always opened early. .
Peri-par otiditis is subdued by cold compresses or ice, locally.
The alvine discharges of Dr. Clark's patients are always
disinfected at once. The way in which this is done is by
placing in the bed-pan or vessel a half pint or a pint of a
solution of the sulphate of iron, just before it is to be used.
The bed-clothes, as soon as they are soiled, are removed from
the bed and plunged into a tub of water, which is sufficiently
impregnated with carbolic acid to secure effectual disinfection.
Dr. Clark is in the habit of administering some mineral
acid in all cases of typhoid fever hydrochloric is that gen-
erally employed but does not think much of the German
treatment by iodine or calomel.
Two-thirds of his patients have been found to do better
without stimulants than with them. A good general rule is
the following: When alcoholics diminish the frequency and
increase the force of the pulse, they do good. In such cases,
tiiey are given in a quantity sufficient to increase the force of
the pulse, and to diminish the restlessness and suffering of the
patient.
Within the last two or three years, the only precaution
taken against contagion, at Bellevue Hospital, has been to dis-
infect the stools. This is done, generally, with sulphate of
iron, which is placed in the bed-pan previous to its being used,
General Diseases. 25
Commercial muriatic acid, diluted, is poured into the pan after
the passage. The stools being disinfected, no further attempts
at protecting the house-staff, nurses, or other patients, are
employed.
The treatment at present in vogue is that of quinine and
baths. This was begun four or five years ago, and has received
such favor that it is quite the routine now. The quinine is
given differently. Perhaps the most popular way Has been
10 grains, two or three times a day, the evening dose being
doubled, if the temperature rises above a particular height,
say 105. It sometimes causes gastric irritation, being given
in powder form. If it is vomited, pills are tried, and finally,
double doses by rectum. Quinidia was used for a short time,
and it reduced temperature like quinine, but irritated the
stomach more. Baths, in every shape, are used, but the
sponge-bath is the form most adopted. The patient's tem-
perature is taken ; if found above a certain height, he is
stripped either entirely naked, or perhaps only the upper half
of the body. He is then sponged over with water, at a tem-
perature .of from 60 to 80. If only half the body is
uncovered at a time, that part is allowed to dry, and it is then
covered, and the rest of the surface sponged. This process is
kept up for 15 minutes. If that is insufficient to reduce the
temperature, it is prolonged to half an hour. It is repeated
every one, two, or three hours, according to the result obtained.
At the end of the bath, a little whiskey is generally given.
The effect of the quinine on the temperature is to reduce
it slightly in a considerable number of cases. Its effect on
the patient is to produce nausea and vomiting in a small
number of cases.
The sponge-baths are almost always pleasant to the patient,
if not too frequently repeated. If given every hour, or two
hours even, they seem to weary and annoy him. They cer-
tainly reduce the temperature in most of the cases. In a
small number of these the reduction seems to last for many
hours. Sometimes, two or three baths given in the afternoon
26 Notes of Hospital Practice.
and evening reduce the fever two or three degrees, and it
keeps down for twelve hours. But it is not very rare that
the baths are given every hour even, without producing very
marked effect. The sponge-bath is a much more efficient an-
tipyretic than quinine. The wet pack is hardly used now.
In one case where it was employed, pneumonia complicated
the disease. The plan of placing the patient in water at a
temperature of 98, and then gradually lowering it, has been
tried a number of times, and so far no deaths can be be traced
to it. But these gradually-cooled baths are uniformly annoy-
ing and depressing to the patients. They don't like them.
Neither have they been proved to reduce temperature perma-
nently any better than the sponge-baths do.
Several cases have been treated upon the Kibbe bed. Its
action and effectiveness were similar to immersion in the bath-
tub. It did not eliminate the fever from the disease.
The results of the treatment of typhoid fever patients at Belle-
vue Hospital, within the past ten years, has shown that large
doses of quinia, and that the antipyretic treatment by cold baths
are unnecessary, and that the employment of mineral acids and
of symptomatic remedies is sufficient.
Dr. Alfred Loomis does not believe in the efficacy of cold
baths or of large doses of quinia in arresting the development
of typhoid fever. He maintains the temperature of the room
iu which the patient lies below 60F. Frequent sponging of
the body with cold water has been of service in his hands. As
soon as the axillary temperature in the evening rises above
103F. he places his patients in a bath of a temperature of
from 70-80F., and then gradually lowers that temperature
until the patient's temperature begins to fall. When the
patient's temperature reaches 103 he is to be taken out and
pat to bed. When his patients are too weak to be put in the
bath he employs the wet pack. He regards cold baths as con-
tra-indicated by feebleness of the heart's action.
As an antipyretic he gives gr. xxx of quinia in one dose, 01
gr. x every half-hour until gr. xxx or xl have been adminis-
General Diseases. 27
tered. He is in the habit of administering an antipyretic dose
of quinia when the temperature has been reduced by the baths.
He lays down the following rules with regard to the use of
stimulants.
1. They are never to be administered indiscriminately that
is, they are never to be given simply because a patient has
typhoid fever.
2. When there is a reasonable doubt as to the propriety of
giving or withholding stimulants, it is safer to withhold them,
at least until the signs which indicate their use become more
marked.
3. In giving stimulants the effects of the first few doses are
to be very carefully watched.
4. Stimulants are contra-indicated by dry tongue, restless-
ness, increasing delirium, pulse and temperature.
As diet he allows at first only milk diluted with lime-water
and later, cream and the yolk of eggs in milk.
Diarrhoea as occurring early in the course of the disease he
allows to go untreated. When it comes 011 in the third or
fourth week he controls it by means of opium.
Tympanitis he relieves by the application of turpentine stupes
to the abdomen.
Hemorrhage is treated by absolute rest, opium, internally,
and ice bags applied over the abdomen.
Bronchitis he has found amenable to dry cupping and the
internal administration of the carbonate of ammonium.
Laryngitis. A small blister is applied on either side of the
angle of the jaw and the whole neck enveloped in a poultice.
Bed-sores are prevented by frequently bathing the parts
with camphor. If the sores penetrate the integument they
are washed with a weak solution of carbolic acid and after-
wards covered with lint smeared over with vaseline.
Headache. Warm fomentations are applied to the forehead,
^rfnong the anodynes the best for the treatment of this symp-
tom are the bromides and chloral.
28 Notes of Hospital Practice.
Delirium is generally relieved by chloral and opium. In
some cases the best results follow the use of stimulants.
Daring convalescence Dr. Loomis regulates the patient's
diet with the utmost care, allowing no indigestible article of
food.
ACUTE TRACOMA.
Cleansing and the use of cold are regarded by Dr. Knapp
as the proper methods of treatment. He rarely resorts to divi-
sion of the outer commissure. He believes that slitting of the
cornea is done too frequently. He employs eserine to reduce
tension. The solution of the drug used contains gr. iv of
eserine to the f f j of water.
LARYNGEAL PHTHISIS.
Dr. F. H. Bos worth first cleanses the parts by means of
one of these solutions :
(1.) R Acid, carbol. cryst
Sodae bicarb.,
Sodse biborat .......................................... aa gr. xxiv.
Glycerinse .................................................. f jss.
Aquae rosae ..................................... q. s. ad. f viij. M.
(2.) R Sodae salicylat ............................................. gr. x.
Sodse biborat ............... . .............................. 9j.
Glycerinae .................................................. f.^j.
Aquas rosae ..................................... q. 8. ad. 3; viij. M.
Whichever of these is employed is best administered by
means of the Sass spray tubes with the compressed air appa-
ratus, at a pressure of from 15 to 20 pounds. The tongue is
protruded and held, thus lifting the epiglottis and uncovering
the laryngeal cavity the patient being directed to sound in
high key A the point of the tube is then passed beyond tUu
crest, and, the pressure being turned on, the cavity is flooded
with the spray. This is repeated several times until the parts
General Diseases. 2V
are thoroughly cleansed. If the application causes pain a 5-
10 gr. solution of morphia, rendered alkaline by the addition
of sodii carb. or potassii carb., is used.
As astringents Dr. Bosworth employs gr. x solutions of th'-
sulphate of zinc; or argenti nitrat., gr. iij-v to f fj ; or ziuci'
chloridi, gr. iij to f |j ; or tannin, et glycerine, f 3j to f |j ; m
liq. ferri persulph., Hfl, xx to f 1 j.
After applying some astringent, iodoform is used, in i<u
following shape :
R Morphise ,. gr. x.
Tannin 55 ij.
lodoform. 3 vj. M.
Et ft. in pulv.
Or else he employs the saturated solution in ether (7fl xl
f j.) The powder is applied by means of the powder-blower.
This instrument was devised by Dr. Andrew H. Smith, of
New York, and consists of a small, open-mouthed bottle,
through the cork of which two tubes are passed, bent at right
angles; to one tube is attached a single hand-ball ; the other
is fashioned to adapt it for the special application to be made.
The powder being placed in the bottle, a single quick pressure
on the hand-ball drives a current of air into the bottle, which
stirs the powder up into a fine cloud, and drives it out, in this
state of fine diffusion, through the other tube, and deposits it,
in an evenly- distributed, thin layer, over the parts which are
to be medicated. Dr. Bosworth does not believe in the use
of the brush, sponge, or probe, as media of medication in this
disease, but regards them as calculated to injure the diseased
parts. He always uses the spray, or insufflator. He does
not think much of the atomizer. He thinks the operation of
tracheotomy a simple one, and one which might be performed
much more frequently than it is, so giving the larynx rest.
NASO-PHARYNGEAL CATARRH.
Cleanliness is regarded as the chief requisite by Dr. \V. F.
30 Notes of Hospital Practice.
Duncan. The diseased mucous membrane is always cleansed
before medicines are applied. The following alkaline and
disinfecting solution has been found to be of service :
R Acid, carbol. ' 3jss.
Sodii bibor.,
Sodii bicarb aa ;ij.
Glycerinse f^ ij.
Aquae q. s. ad iOij. M.
This is used in the atomizer, the post-nasal syringe, or the
douche. The best method, in Dr. Duncan's opinion, is that
by the post-nasal syringe. It is entered flat on the tongue,
which is depressed by its nozzle; its point is then quickly
introduced behind the palate, and the contents suddenly and
forcibly ejected by driving home the piston. The hand-ball
atomizer, when used with about 30 pounds pressure, has been
found to be very efficient in dislodging mucus from the supe-
rior meatus. It is better for children than the post-pharyn-
geal syringe.
Medicines are applied in the form of spray, powder, or
solution. The spray is regarded as the best medium. As an
efficient astringent, Dr. Duncan employs gr. xv of the sulphate
of zinc to the f ij of water. If the case is a mild one, a
solution is not more than one-fifth this strength. Applica-
tions are made three times a week, and in the intervals, the
patient applies the cleansing solution above given, himself, by
means of Delano's atomizer, or the post-pharyngeal douche.
When there is excess of secretion, and but little sensibility,
ferric alum (gr. v-xx to aqua f 3 j) has been found to be useful.
His general rule is to ring the changes on astringents until a
good one has been found. Others than those already men-
tioned, which he employs, are chlorate of potassium, nitrate
of silver, tannin, and chloride of zinc. When pain follows
the use of an astringent, a spray of morphia is employed.
When stronger applications are needed, caustics are applied
with a probe, one end of which is tightly wrapped with
cotton.
General Diseases. 31
The probe employed has a short arm of an inch in length,
so that applications can be made with it behind the palate to
the vault. Hypertrophied tissue is always destroyed by
means of forceps, knife, or galvano-cautery. Polyphoid thick-
ening of the ends of the turbinated bones is touched with
caustic applied by means of a probe passed through a shield.
Where there is adenoid degeneration the vault is curetted.
In the.atrophic form of naso-pharyngeal catarrh, stimula-
ting solutions are employed by means of the spray, such as a
weak solution of iodine, (gtt. v-x to aqua f | j,) or tincture of
sanguinaria, (f3j to aqua f f j.) Sometimes, sanguinaria,
myrrh and lycopodium, in powder, is blown into the nostrils.
The simple ozsena is treated by carefully removing the
pellicle every day or so, and then using an astringent spray,
after which iodoform powder is blown into the nostrils. The
nasal passages are kept constantly open and dead bone is re-
moved at once.
THE LARYNGITIS OF LEPROSY.
Dr. Louis Elsberg cleanses the larynx thoroughly with the
spray and then administers soothing inhalations. A diluted
emulsion of garjun oil has acted very well in his hands as a
local as well as an internal remedy. He has had excellent
results from local applications of a solution of iodoform in
sulphuric ether.
CHRONIC BRIGHT S DISEASE.
The diet allowed at Bellevue Hospital, in this disease, con-
sists mainly of milk, eggs, butter and fresh fish. Meat and
fried fats are not allowed. Those vegetables containing the
least amount of woody fibre, such as rice, potatoes and onions,
are given freely. Asparagus, turnips, cabbage and beans are
not desirable. For the anaemia, iron is administered in the
32 Notes of Hospital Practice.
form of the tincture of the chloride, combined with nux
voraica and sweet spirits of nitre :
R Tc. ferri chlor.,
Tc. nuc. vom...., aa f.^ij.
Spts. ether, nit f^jss. M.
Sio. A teaspoonful thrice daily.
Cod-liver oil is given to increase the nutrition, and to com-
bat the disease itself the following prescription is employed :
R Hydrarg. chloridi corrosivi gr. j.
Ex. dig.,
Quinise sulph aa gr. xx. M.
Et in pil. No. xx div.
SIG. One pill three times a day.
To let out the serum from the legs punctures are made in
the skin and the legs then wrapped in cloths wet in a solution
of carbolic acid in water, to which essence of cinnamon has
been added. The patient is rubbed all over once a day with
sweet' oil.
THE MANAGEMENT OF THE DIARRHCEAS OP CHILDHOOD.
Beef Tea in Diarrhoea. Dr. Smith has found that beef tea
in the diarrhoea of children almost invariably acts as an irri-
tant and aggravates the disease. Sometimes it seems to pass
the bowels in the same form in which it was taken. In any
case of acute diarrhoea he advises not to give beef tea.
The Reduction of Temperature in Diarrhoea. The best
means of reducing the temperature according to Dr. Smith is
by the external application of cold. Since Kibbe's .cot has
been devised, the immersion of the child in a bath is practi-
cally done away with. Kibbe's cot can be improvised easily ;
it is a pleasant and convenient way of giving the wet pack ;
is just as eifectual as the bath, and has very few of its objec-
tions. Fold a small sheet so that it will cover the child from
the axillae to the ankles, place the child on the bed, leaving
General Diseases. 33
the arms and feet uncovered. The axilla can be dried easily,
and the temperature be taken while the child is in the pack,
or the thermometer is introduced into the rectum, the most
accurate way of taking the temperature. Water of the desired
temperature is poured on from a pitcher. In cases of slight
elevation of temperature, say to 102 F., or under, sponging
off the body with water about the temperature of 80 F. has
usually been found to answer the purpose, and it is done often
enough to reduce the temperature nearly to normal. But in
all cases of an elevation of temperature above 102 F. resort
is had to the Kibbe's cot or its substitute. Dr. Smith always
remains and makes the first application himself. The tem-
perature of the water used is at first 90 F., then gradually, as
the child becomes accustomed to it, it is made cooler, until it is
brought down to 80 F. in a few minutes. It has been found
to be necessary where the temperature is very high, or where
it rapidly rises after it has been reduced, to apply the water
even colder than 80 so as to reduce the temperature to 99.
It usually goes down still farther after the child is taken out.
After removing the sheet, the child is put in a thin blanket,
covered up and allowed to go to sleep. In very severe cases,
where the temperature rises to 105 F., or higher, it is neces-
sary to apply the cold every hour or two. In such cases it is
not necessary to remove the child from the Kibbe's cot, but it
may be allowed to remain there for days if necessary. The
cot is made comfortable by folding a woolen blanket and put-
ting it under the child.
Dysenteric Diarrhoea, Dr. A. A. Smith has found small
doses of castor oil and opium, given in mucilage, an excellent
combination in this complaint, as in the following prescrip-
tion:
R Ol. ricini 3J.
Sacch. lactis gss.
Tinct. opii camph tt\,xxxij-f3Ja
Mucilag. acacise,
Aquae purae aa q. s. ad Jj. M
SiG. One drachm every two or three hours.
34 Notes of Hospital Practice.
The paregoric should be added according to the age of tho
child : for a child under a year, 4 to 8 drops ; for a child of
one to two years, 10 drops. The diet is, at the same time, to
be carefully regulated. It has been found well, sometimes, in
these case, to give starch-water enemata. If the enemata are
given, the paregoric is left out of the castor-oil mixture, and
laudanum is put in the enema. One or two drops of lauda-
num, with one to three tablespoonfuls of starch-water, are
given, according to the age of the child. The starch-water is
made about as thick as thin cream, and given tepid. It is
repeated every three to six hours, according to the severity of
the attack.
Flatulent Diarrhoea. Dr. Smith has found the following
prescription an excellent one in such cases :
H Magnes. calcin ,"j.
Spts. amm. aromat Tt^xl.
Tinct. assafcet gj.
Anisette vi.
Aq. cinnamomi q. s. ad % iv. M.
SIG. 3.j every half hour until relieved, to a child from three weeks
to four months old.
Two or three doses will usually relieve.
Koumyss in Diarrhoea Dependent Upon Non-Digestion of
Sugar. Dr. Smith has found this to be a combination that is
easily assimilated. The koumyss is charged with carbonic
acid gas, but children do not take it readily with the gas in.
It is gotten rid of by taking the koumyse out of the bottle and
pouring it from one pitcher to another a few times. A small
quantity is kept out for immediate use, and the remainder put
back into the bottle and the bottle corked and put in a cool
place. Sometimes children who are unable to retain anything
else, have been found to take a teaspoonful of koumyss at a
time and digest it, and frequently, without any medicinal
treatment, will recover under its use. Dr. Smith has found
that twelve hours is as long as it can be kept safely, after
once uncorking it. The child need take no other food while
General Diseases. 35
it is taking the koumyss. It is itself food and drink. It is
sour, and mothers are tempted to sweeten it to make it palat-
able. It is never to be sweetened, and never to be given
within two hours after any other form of milk, and must be
given cold. After the first repugnance to it, children take it
quite readily ; even children as young as six or eight months
can be made to take it by taking advantage of their thirst and
giving it at first in small quantities. Koumyss may be used
in many forms of diarrhoea because of its easy digestion. That
made by Dr. E. F. Brush, of New York city, is the only
preparation of it which Dr. Smith has found reliable.
Diarrhoea Due to Inflammatory Disorders. The indications
according to Dr. Smith, are to reduce the temperature, regulate
the diet, surround the child by the best possible hygiene, put
the warm applications over the abdomen, and give internally
a combination of opium and camphor. Tully's powder, which
consists of morphine, camphor, and prepared chalk, has been
found to make a good combination. The dose for an adult is
the same as Dover's powder. Ten grains contain one-sixth of
a grain of morphine and a little over three grains of camphor.
A child three to six months old is given an eighth of a grain
every two to six hours, according to the severity of the attack
and the control the powder has over it. A child six to eighteen
months is given one-sixth to one-fourth of a grain in the same
way. After the acute symptoms have been controlled there
remains in many cases a tendency to looseness of the bowels,
with very little constitutional disturbance. The Tully's pow-
der is then stopped and the following given :
R Ac. sulpli. dil fl\, xxiv.
Salicin gr. xxiv.
Glycerinse % iij. M.
SIG 3!. t. i. d.
This should not be given within a half-hour of the taking
of milk. The sulphuric acid has a tonic and astringent effect,
and the salicin, besides its tonic effect, acts also as an anti-fer-
mentative.
36 Notes of Hospital Practice.
Diarrhoea Due to Errors in Diet. Dr. Smith teaches that a
child under eight months ought to have no other diet than
milk, and that even up to two years milk should be its main
diet. Human milk he regards as the best during the first
year, or until weaning. During the first eight months cow's
milk diluted one-fourth with barley-water makes a fair diet.
The ground or crushed barley is boiled with water of sufficient
quantity, so that when cold it is about as thick as thin cream.
The milk is given about blood-warm and a little sweetened.
Dr. Smith has tried the condensed milk with children thor-
oughly, and has seen it tried in the practice of others, and
protests against its use. He thinks that children fed on con-
densed milk, although they may thrive well apparently, yet
when they fall ill show very little resisting power, and, parti-
cularly when they fall ill of diarrhoea, weaken very rapidly
and the diarrhoea is apt to be obstinate. He holds, however,
that there are exceptional cases in which it may be used, and
some cases in which it is desirable to use it for a short time.
When bottle-fed children suffer from diarrhoea he is accus-
tomed to boil the milk and make the barley water thinner
and give more of it, say one-third barley water to two-thirds
boiled milk. He has found thoroughly cooked wheat-flour
an admirable food for children with diarrhoea, and prepares it
in this way : Put about two pounds of flour in a muslin bag,
tie a string around the top of it, and suspend it in a kettle of
water and boil it for five hours; then let it get cold. Take
off the bag, cut off the outside dough and grate it. Thicken
boiled milk with this to about the consistency of a thin gruel,
or about thick enough for it to pass through the rubber nipple
of a nursing bottle. He thinks that all food for children
should be thoroughly cooked. Still more is this to be ob-
served when they are ill of diarrhoea. As a rule, he teaches
Jhat children suffering with acute diarrhoea should be fed with
just as little food as will satisfy their hunger. Often a little
cold water will relieve their thirst and lessen the desire for
food. ^ Icoholic stimulants are avoided unless there is exhau?-
General Diseases. 37
rion. Champagne iced is given in small quantities, if there is
obstinate vomiting".
Diarrhoea Due to Prceturnafural Acidity. Such children
are given, with good effect, a teaspoonful of lime-water three
times a day. This is given in two teaspoon fuls of milk.
Chalk may also be given. Dr. Smith has found the mist,
cretce of the Pharmacopoeia to be a good preparation. It con-
tains, besides the chalk, gum arable, glycerine and cinnamon,
all of them good in this form of diarrhoea. Sometimes it has
been found well to give a laxative, as some of the cheesy
masses may have collected in the intestines, and may be acting
as irritants. The indication is to remove them. He has
found the following prescription a better one to give than the
traditional castor oil :
H Pulv. rhei. rad gr. xv.
Sodas bicarb gr. xxv.
Aq. menth. pip ^ ij. M.
SiQ. One teaspoonful, as a laxative to a child from one to four months
old.
This prescription gives the laxative effects of rhubarb, with
its so-called secondary astringent effects, as well as the alkali,
and the sedative, and antiseptic effects of the peppermint.
In any case of diarrhoea, where there is reason to believe
there is any irritant in the intestines, the treatment is begun
by giving a laxative to remove it.
The Diarrhoea of Dentition. Lancing the gums never does
harm. Dr. Smith thinks it better to err on the side of lancing
them when there may be no necessity, than to fail to lance them
when there might be necessity. He has often seen a child
having from ten to twelve movements a day relieved entirely
by lancing the gums, and with no other treatment. It is in
these cases that the bromides have proven so effectual. He
gives the following combination of a bromide with mucilage,
to a child between six months and a year; older children a
larger dose :
38 Notes of Hospital Practice.
R Sodii bromid %ss.
Mucilag. acacise,
Aquae purae aa q. 8. ad % ij. M.
Sio. A teaspoonful every three hours.
The bromide diminishes the reflex disturbance, and the
mucilage is soothing to the irritated intestinal mucous mem-
brane.
General Hints. Whatever the cause, Dr. Smith insists that
all children, whether infants or those older, be kept quiet when
suffering from diarrhoea. They should be kept, according to
his thinking, in a partially darkened, quiet room, free from
noise, and all talk in the room should be avoided, especially
when the child is asleep. The nervous system in childhood
is so impressible that it is easily disturbed, and any disturb-
ance of this character aggravates the diarrhoea. Infants under
one year are kept lying down as much as possible. They are
not jolted up and down as is the custom of most nurses and
some mothers, in order to amuse them. If the child is under
one year of age it is placed on a pillow, if the diarrhoea is
severe, as it can be kept quiet more easily in this way than
when lying on the lap. Even in changing the napkin care
is taken to move the child as little as possible. The room in
which the child lies is kept well ventilated. Mothers usually
are over-careful for fear the child may take cold, and on this
account are apt to keep the room too closely shut up. When
the child is awake it is carried carefully into open air, always
in the shade. Dr. Smith believes salt-air to be beneficial to
almost all forms of diarrhoea in children, and especially as
occurring in city children. In all cases, in children under a
year, if the diarrhoea is severe, warm applications are applied
over the abdomen in the shape of a spice bag. To make this
take a half ounce each of cloves, allspice, cinnamon, and anise
seeds pounded, but not powdered, in a mortar, put these be-
tween two layers of coarse flannel, about six inches square, and
quilt them in. Soak this for a few minutes in hot spirits
(brandy, or whiskey, or alcohol), and water equal parts, and
General Diseases. 39
#pply it to the abdomen warm, renewing it when it gets cool.
In this way it is possible, not only to get the effects of a poul-
tice, but also the sedative and antiseptic effects of the spices.
Great heat, with influences that depress the nervous system,
bad hygienic surroundings, improper diet, too early weaning,
bottle food, and dentition, are among the causes that predis-
pose to diarrhoea. In all cases these must be removed.
CJiolera Infantum. The two special indications are to re-
duce the temperature and control the nervous manifestations.
Cold applications are made. Hypodermic injections of quinine
and morphine are given : To a child of six months, 1 grain of
quinine and about V200 ^ a S ra ^ n f morphine every four or
six hours, according to the indication ; for each additional
six months of age, an additional grain of quinine and an ad-
ditional 1/200 f a grain of morphine. These are the solutions
of quinia and morphia which Dr. Smith uses:
R Morph. sulph gr. ss.
Aquae destillat g j. M.
SiG. Five minims, by hypodermic injection, for a child six months
old.
A Quiniae sulph jj.
Ac. sulph. dil q. s.
Acid carbol. cryst gr. v.
Aquae destillat ^ j. M.
SiO. Eight minims, by hypodermic injection, for a child six months
old.
Usually, the stomacn is so irritable that medicines and food
are both vomited. After the temperature is reduced, and the
nervous system is rested, small quantities of food are given.
Small pieces of ice are also given to allay thirst.
The indications for treatment in the exhaustive form of
the disease are thought by Dr. Smith to consist in checking
the enormous loss of fluid and in sustaining the patient. His
main reliance is on opium and alkalies and stimulants.
Opium, in small doses, in addition to the other effects claimed
40 Notes '<yf Hospital Practice.
for it, he regards as a cardiac stimulant, thus meeting one of
the chief indications in this disease.
The following combination is good:
R Tine. opii. camph giij.
Mist, cretae j ^iy M.
SIG. A teaspoonful -every gecond or third hour to a child of six
months.
Sometimes nothing is retained by the stomach. In such
cases, it is necessary to give the opium hypoderrmeally in
1 /200"g ra ^ n doses, without the-quinia.
Alcoholic stimulants are given, and among them brandy is
considered to be 'best. Dr. Smith gives 5 drops of brandy in
a teaspoonful of water, every hour, to a child of six months,
if there is great exhaustion. This quantity is increased or
diminished, according to the indications. In some eases of
cholera infantum, a child becomes suddenly much more ex-
hausted, pulse becomes more rapid, extremities are cold, per-
spiration comes out freely, and the child seems to be going
into collapse. An enema of hot water sometimes revives such
a child Avondi-rfully. A good quantity of hot water must be
used, say half a pint, and a towel must be held to the anus
afterward, in order to have the water retained as long as pos-
sible. Along with this, spirits of camphor are given internally,
in from 6 to 10-drop doses. It may be put in with the
brandy, and the two given together .for a few hours. In any
case of diarrhoea, where these symptoms of great exhaustion
occur with the coldness of the extremities, the hot water
enemata may be given.
TYPHOID FEVER IN CHILDREN.
Dr. A. Jacobi considers typhoid fever in childhood as a
very manageable disease, if taken in time.
High temperature he reduces by naeai>s of the cold bath,
and if reaction is not at once established he plunges the child
into a hot bath, which has the efifeet of restoring the circu ] ation
General Diseases. 41
on the surface of the body and thus enabling the blood to
throw off a part of its heat. Where the child will not bear a
cold bath, he bathes the surface of the body with cold water as
far down as the thighs.
He regards cold packing of the trunk and abdomen as of
great service. The child is retained in the pack until both
pack and surface become slightly warm.
When temperature is high he gives quinia from 8 to 15
grains daily in one or two doses. If the temperature is very
high, from 12 to 16 grains are given at a dose. He always
administers it in solution and in the form of the muriate, or
neutral tannate.
He does not hesitate to recommend salicylic acid and salicy-
late of sodium in the reduction of high temperatures. He
gives salicylate of sodium to a child in doses of 3 to 6 grains,
three, four, or five times in the course of twenty-four hours.
He has sometimes succeeded in reducing temperature by a
combination of quinia and salicylic acid where both remedies
failed to do so when employed separately.
Now and then he uses digitalis, in small doses, to invigorate
the heart's action. Veratrum viride he does not recommend,
by reason of its occasional irritant effects upon the mucous
membrane of the stomach and intestines.
He believes stimulants to be especially indicated, and gives
a baby one year old an ounce of brandy or whiskey in the
course of twenty-four hours. He always gives them in milk,
water, or barley-water, and never alone.
Camphor he regards as an excellent stimulant, and gives
from 2 to 10 grains of camphor, in the course of a day, to a
child from two to four years of age. Musk, also, he regards
as a valuable stimulant. The dose for a child two years old,
is 2 grains, to be repeated every hour. With it he has ob-
tained admirable results, when nothing else seemed to be of
any avail whatsoever. When a speedy effect is desired, he
does not rely alone upon the internal use of stimulants, but
proceeds at once to inject, hypodermically, ether, brandy, alco-
42 Notes of Hospital Practice.
hoi, or camphor dissolved in ether, oil or brandy. He is very
careful that the solution of camphor thus obtained is not too
strong, in which case the menstruum is absorbed very rapidly
and the camphor is left remaining in the subcutaneous tissue.
Hemorrhage from the bowels Dr. Jacobi treats by opium
and alum. In some cases he has had excellent results from
the steady application of an ice-bag over the ileo-caecal valve.
HEADACHE.
Nervous Headache. Dr. A. A. Smith has found this form
will very often yield to a saline cathartic. In addition to the
cathartic, he uses this formula :
R Sodii bromid ......*, ~. % vj.
Elix. valer. ammon f^ iv. M.
SIG. A teaspoonful every hour until relieved.
When the headache is associated with anaemia, he givej
iron in addition to the above, and stimulates the heart with :
R Ammon. muriat.. .. Jfss.
Tc. actaeae racemos.,
Aquae aa fg iij. M.
SIG. A dessertspoonful, after meals, in a wineglassful of water.
Where there is despondency and depression of spirits, he
frequently uses, thrice daily, a pill composed of gr. 1/50 of
phosphorus, and gr. 1/g of nux vomica.
If there be persistent sleeplessness, he gives :
R Camph. pulv gr. xxv.
Ext. cannab. ind gr. x.
Ext. hyoscyami gr. xx. M.
Et. in pil. No. r div.
SlG. One at night ; repent in two hours, if necessary, to product
sleep.
Sick Headache. Good results have been obtained from the
use of guarana or paullinia sorbillis. The latter is adminis-
tered in powder, 15 grains being given every fifteen minutes
General Diseases. 43
until six doses have been taken. It has been found best to
give it in a little sweetened water.
Malarial Headache. The treatment is begun by adminis-
tering 15 grains of quinia every two hours before the expected
attack. If quinia fails to ward off the attacks, Fowler's solu-
tion and tincture of belladonna are given in 5-drop doses.
Headache Dependent on Gout, This is combated by means
of the following,-
R Yin. colch. sem .......... ~ .................. ____ ..
Lithii bront,
Syr. zingiber ..... ..^. ........... .. ......... ...,~. ..... -aa f^ ss.
Aq. cinnnmom .................................. q. s. ad f^ vj. M.
Sio. A tablespoonful in a tumblerful of Vichy water every few hours.
The Headache ef Syphilis, Calomel is given in doses of
the l/io f a g ra ' n every hour during the day. This treat-
ment is continued for two or three days and then stopped, and
iodide of potassium given in 15-grain doses at meals. This
amount is gradually increased until iodism is produced.
The Headache of Rheumatism* He uses the mild faradic
current to the scalp, and internally the following :
R Potns. iod.,
Ammon. muriat ............ *......... .... ..... -..aa J^iss.
Infus. humuli...^.. ....................................... f^ vj. M.
Sio. A tablespoonful four .times a day, in a wineglaseful of water.
In cases which do not yield to this treatment, 20-grain doses
of the bromide of ammonium have been found effectual.
Urcemic Headache. Dry cups are applied over the region
of the kidneys, and the following given internally :
R Potas. acet ............. ............ .............. ... ^vj.
Infus. digital .............................................. ^ vj. M.
SIG. A tablespoonful every three hours.
The infusion is made from fresh English leaves. This
mixture is administered until the kidneys act freely. If it
44 Nates of Hospital Practice.
does not relieve the headache within 24 hours, a saline cathar-
tic is given. A domestic remedy often employed consists of
an ounce of cream-a-tartar in a quart of water. The whole
of this is taken in the course of 10 hours, and acts both as a
cathartic and diuretic.
The Headache of Cerebral Effusion. If convulsions seem
to be imminent, the kidneys are stimulated by means of the
digitalis and acetate of potassium mixture, given above, and
from 12 to 20 ounces of blood are taken from the region of
the kidneys, by means of wet cups.
The Headache of Acute Alcoholism. To remove the alcohol
from the intestinal canal, give drachm each of rhubarb and
calcined magnesia, and then administer :
R Spts. ammon. aromat
Tc. camph
Tc. hyoscy
Spts. lav. comp ................................. q. s. ad f^ ij. M.
SlO. A teaspoonful every hour, until the headache is removed.
Gr. ij of capsicum and gr. iij of quinia are then given
before each meal, for several days.
If there is sleeplessness, the following formula can be
used :
R Sodii bromid ............................................. .^ss.
Chloral hydrat ........................................... 5 ij 93 -
Syr. aur. cort ............................................. f^ss.
Aquae .......................... , ............................ f,f iijss. M.
SIG. A tablespoonful at night. To be repeated in two hours, if neces-
sary, to produce sleep.
Dyspeptic Headache. If there is indigestible food in the
stomach, an emetic, such as mustard and warm water, or gr.
xv of the sulphate of zinc, is given. If the headache is
frontal, 10-drop doses of nitro-rauriatic acid, well diluted, are
given after meals. If the pain is located about the roots of
the hair, gr. xx of the bicarbonate of sodium or magnesium,
are given before meals.
Genwal Disease*. 45
When the pain spreads over the entire bead, Dr. Smith
gives:
R Sod. bicarb ......... ---- ............. ------ .....
Ac. nitro-mur. dil ....................................... f % ij.
Tc. nuc. vora ............ ~ ........ ..................... ... fjjss.
Syr. aurant. cort .......................................... f^^j-
Aquae .............................................. q. s. ad f^ vj. M.
SiO. A tablespoonful, after meals, in a wineglassful of water.
If there is gastric pain, a mustard-plaster is applied to the
epigastrium. If flatulence is troublesome, bismuth and mix
vomica are given combined :
R Bismuth, subcarb.... ........... * ........ * ........ . ....... 3Jss.
Tc. nuc. vom ...... .................... ~ ..... ........... f^jss-
Tc. card, co.,
Spts. lav. comp .............................. aa q. B. ad f ,f iv. !M
SiO. Two teaspoenfuls, before meals, in a wineglassfal of water
If there is constipation, the following pill is given:
R Aloes pulv ...................... ...... ...... ....... ...... 3 es.
Ex. nuc. vom. ....... ..... .......... ................... ~. gr. v.
Ex. belladon ------- .. ............................... _________ gr. iv. M.
Et. in pil. No.-xv div.
In other forms of headache associated with indigestion, a
single drop of the tincture of nux vomiea is given every fifteen
minutes until 10 or 15 drops have been taken.
Where headache depends on delayed stomachic digestion, |
a drachm of saccharated pepsin, in a wineglassful of sherry
wine, is effectual.
The Headache of Acute Cerebral Congestion. The patient
is kept in a darkened room, perfectly quiet, and cold and
evaporating lotions are applied to the head. A saline cathar-
tic- is first administered, and then the following :
R Sodii bromid
Fl. ex. ergot ............ ~ ......................
Syr zingiber ........... ~ ..... ........ ~ ................... f^ss.
Aq. aurant. flor .................................. q. s. ad f.^ iv.
Sio. A tablespoonful every two hours.
46 Notes of Hospital fracace.
If the skin is hot and dry, ami the pulse full and rapid, 2
drops of Fleming's tincture of (he root of aconite are given
every two hours until the heart's action is sensibly reduced.
The Headache of Passive Cerebral Congestion. The heart's
action is stimulated by the use of the following :
R Tc. digital
Spts. ammo, aromat .............. .
Spts. lav. comp.,
Syr. simp ..................................... aa q. 8. ad f% iij. M.
Sio. A teaspoonful every four hours.
The Headache of Cerebral Anosmia. The patient is al-
lowed to inhale from 3 to 5 drops of the nitrite of amyl,
placed on a piece of cotton and applied to one nostril while
the other is closed.
When associated with nervous exhaustion, this formula ia
osed :
H Strych. sulph ............................................. gr. as.
Tc. ferri chlor. ............................................ ^3 l j-
Glycer ...................................................... f^sa.
Infos, gent ....................................... q. 8. ad f^ vj. M.
Sio. A tablespoonful, after meals, in a wineglassful of water.
A tablespoonful of brandy after each meal, and a glass of
champagne at dinner, are often of great advantage in these
cases.
The Headache of Cerebral Tumors. The iodide of potas-
sium is the indication followed.
The Headache of Cerebral Softening. This is palliated by
opium and rest. Ergot in large doses f3j-f3iv of the
fluid extract thrice daily has been employed in several cases
of this kind, by Dr. Smith, with admirable effect.
CATARRHAL INFLAMMATION OF THE MIDDLE EAR.
Dr. Samuel Sexton treats these cases by means of an instru-
Notes of Hospital Practice. 47
merit consisting of a soft rubber bulb, connected by a flexible
tube with a hard rubber nozzle which is somewhat olive-shaped
and adapted to fit into the entrance of the external auditory
meatus. When used, the nozzle of the instrument is held to
the ear with the left hand of the operator and pressed against
the opening with sufficient force to make the fitting as nearly
air-tight as possible; while the bulb is held in the right hand,
to be manipulated as desired. Care is always had in using
this instrument not to employ two much force in stimulating
the membrana tympani. When the instrument is used for
suction, so as to draw the membrane out as far as possible, the
ball is simply collapsed by pressure of the right hand before
the nozzle is applied to the ear. Upon removing the pressure
of the hand, the bulb, by its own elasticity, gradually resumes
its expanded condition, thus rarefying the air in the external
meatus. If it is desired to give the membrana tympani and
ossicula motion, the bulb is alternately compressed and ex-
panded while the nozzle is in contact with the ear. Where
inflammation is high, leeches are applied and warm water
instillations are practiced.
CHRONIC BRIGHT'S DISEASE.
Milk is used freely. The diet is rendered noBrnitrogenous -
as far as possible. Cod-liver oil is given in combination with
the following mixture :
R Tr. ferri muriat.,
Tr. nucis vom ... aa gtt. x.\
Spts. etheris nitrosi f^j. M. .
SiG. To be taken thrice daily.
if the patient is troubled with gastritis, the iron and cod
liver oil are stopped and cream of tartar administered as a
purge. I^arge doses of pepsin and of the oxalate of cerium
are used to quiet the stomach. The specific treatment of this
disease at Bellevue Hospital consists of the following :
48 General Diseases,
& Hydrarg. bichlor gr. J^.
Quin. sulph aa gr. j. M.
SIG. To be given thrioe daily.
The skin is freely rubbed with olive oil twice daily.
CATARRHAL LARYNGITIS.
To break up the tendency to a continuation of the disease,
after recovery from the attack, the child is given the follow-
ing mixture, at Bellevue Hospital:
R Hydrarg. chlor. mit.,
Quiniae sulph aa gr. j. M.
SIG. To be taken three times a day until 6 grains of the calonuJ
have been administered.
THE GENERAL TREATMENT OP CONSTIPATION
Constipation Dependent Upon Deficient Secretion. Dr.
Thomson believes that the use of cathartics or of medicines
calculated to stimulate nerve action, only does harm in this
condition. The best results have followed the use of large
quantities of water. His patients are directed to take two
tumblerfuls of water upon rising. A small amount of com-
mon salt may be added to this water to increase its laxative
effect. He has found that the addition of small quantities of
quinia to salines increases their power; for instance, he gives
R Mag. sulph ~. ~ 3j;
Quin. sulph .. gr. j,
in a tumblerful of water every morning. He does not plaof
much confidence in the value of fruits as laxatives.
Flatulence is overcome by the following :
R Assafoet gr. IT.
Saponis gr. ix. M.
SIG. To be taken when necessary.
Notes of Hospital Practice. 49
Constipation Due to Want of Peristaltic Action. A sitz-
bath is ordered every night, the water used being as cold as
the patient can bear; or, upon rising in the morning, the spine
and abdomen are sponged with cold water. In other cases,
great benefit is derived from dashing water against the abdo-
men while the patient stands up. Nux vomica, combined
with soap and rhubarb, has proved very serviceable. The
application of the faradic current, one pole of the battery being
placed over the spine, and the other passed up and down over
the abdominal walls, has often been of great benefit. In still
other cases, the health-lift is recommended.
Constipation Due to Chronic Inflammation of the Rectum.
The rectum is emptied by means of enemata. When it is
thoroughly cleansed out, strychnia is injected locally, a fold
of the mucous membrane being drawn down and the needle
inserted. This same hypodermic method has given the most
excellent results in Dr. Thomson's hands in cases of constipa-
tion accompanying enlarged prostate. In every instance the
rectum is first thoroughly emptied by means of an enema.
Kissengen water is prescribed in the morning, and a supposi-
tory of belladonna, or stramonium, used at night. Faradiza-
tion along the course of the colon, and hip-baths > .are also of
service.
Constipation Following Febrile Diseases is treated by means
of the compound jalap powder.
Constipation Associated with Chlorosis. Dry heat is applied
to the feet and hands. In addition to the dry heat, the feet
and arms are wrapped in cloths dipped in a solution of capsi-
cum. The same application is made over the abdomen.
After these measures have been, continued for some time,
cathartics are administered, the one most generally employed
at Bellevue Hospital being the compound rhubarb pill. Of
these, three are given at night, twice a week, or given every
night until the bowels have been, rendered soluble. Iron is
not used until the bowels have- been rendered soluble. The
50 Notes of Hospital Practice.
form in which it is most frequently prescribed is the fol-
lowing :
R Potas. bicarb...' .........
Ferri sulph.,
Ex. nucis vom ........ aa gr. r. M.
Et in pil. No. xx div.
Sio. One after each meal.
To restore tone to the muscular coat of the intestines, bella-
donna and nux vomica are thus combined with eoloeynth :
R Ext. belladon .. gr. v.
Ext. nucis vom . gr. x.
Ext. eoloeynth. co . 3J. M.
Et in pil. No. xx div.
SIG. One at bedtime.
If the eoloeynth causes griping, it is prevented by the
addition of 3 ij of the bicarbonate of sodium and the divi-
sion of the above mass into 40 pills, the dose being doubled,
i. e. } two pills are to be administered to the patient at bed-
time, instead of one.
FAVTJS.
Dr. H. G. Piffard removes all the superficial crusts by scrap-
ing them off or digging them out with a pen-knife or small
spatula. He first, however, loosens them by means of poul-
tices or frictions with oil. After the crusts are all removed,
(he parts are smeared with sulphur or turpeth ointment (3 to
5 per cent.) The hairs are then pulled out, one by one, by
means of a properly constructed forceps. After the hairs have
been pulled out, a solution of the bichloride of mercury (2 or
3 grains to the ounce) is thoroughly rubbed in.
DISEASES OF THE HEART.
Valvalar Lesions. Dr. Flint advises this class of patients
not to overtax the heart, allowing only just such an amount of
physical exertion as can be done with entire comfort. He
General Diseases. 61
is.ys down the same rule with regard to mental excitement.
When there is co.-existent dilatation of the left ventricle aud
consequent dropsy, hydrogogues and diuretics are prescribed.
To relieve dyspnoea, opiates and ether are administered. When
the action of the heart is feeble and irregular, from 10 to 16
drops of the tincture of digitalis are given at short intervals-
The chalybeates are indicated if anaemia be present.
Aortic Lesions. He uses digitalis with a certain amount o f
reserve in the treatment of aortic lesions.
Angina Peetoris. He treats the paroxysms by the free ex-
hibition of alcoholic or ethereal stimulants either brandy or
Hoffman's anodyne; to this a few drops of laudanum are
added with advantage. Nitrite of amyl is also inhaled and
generally stops the spasms promptly.
CONTUSIONS.
This is the method of treatment employed at Bellevue Hos-
pital. The parts are fomented continually with simple hot
water until the pain ceases, and the contusion is then kept wet
with the following lotion;
R Ammon. rauriat .......... ... ............ ...... ...... ... ..... ^ ij.
Aceti,
Aquse.. ..... ..... .............. ......... ... ....... , ..... ,..aa f J ij. M.
SCARLET FEVER.
The diet upon which all Dr. Thomson's patients are placed,
consists of milk, either alone or witli lime-water. In a certain
class of cases he employs the carbonate of ammonium freely,
but his general method of treatment until quite lately has
been by the chlorate of potassium and dilute muriatic acid
(gr. Ixxx of the former and f3ij of the latter, during the
course of the 24 hours, diluted with Oij of water.) Now he
substitutes the bromide of potassium for the chloride. The
52 Notes of Hospital Practice.
solution employed consists of a saturated solution of the bro-
mide of potassium in water, to f 1 ij of which f j of bromine is
added very slowly, the bottle being shaken constantly while
the combination is being made. Dr. Thomson has found it
better to add half of the quantity of the bromine first, and
then to let the bottle stand for an hour or more before the
remainder is added. When the bromine is dissolved in this
manner, the bottle is filled with water until a 4-ounce mixture
is made. For internal administration f 3j of the solution to
f ij of water is used, and of this a teaspoonful is given in a
tablespoonful of sweetened water, p. r. n. The solution is kept
in a dark place. Equal parts of this solution and of glycerine
are used as a local application.
He advises occasional purges composed of gr. iij of calomel
and gr. v of jalap. Rapid rise of temperature to 104-106
he meets by the douche of ice- water to the head or by the cold
pack. He does not recommend the cold bath. His way of
administering the wet pack is this he takes a sheet, wrings
it from water at the ordinary temperature, wraps the child in
it and over that lays one wrung from ice-water.
He recommends that from the very inception of the disease
the body be oiled over three times a day; this relieves the itch-
ing and reduces the temperature. To relieve nephritis he
employs the hot water pack, dry cups, counter-irritation over
the kidneys, digitalis and warm water injections.
RUM STOMACH.
Dr. Alfred Loomis prescribes equal parts of the compound
tincture of gentian and of columbo with gtt. v xv of the
tincture of nux vomica, before meals. He also employs occa-
sional aloetic and mercurial purges.
EMPHYSEMA.
Dr. Francis Delafield prescribes, when iodide of potassium
General Diseases. 53
and all other remedies fail, gtt. xxv of aromatic sulphuric
acid four times a day.
DIABETES INSIPIDUS IN CHILDREN,
Dr. Delafield administers the fluid extract of belladonna jn
email doses, or in some cases uses' gtt. v of a gr. j to the f j
solution of atropia once a day. If well borne the dose is in-
creased to 5 drops twice a day, and so on until gtt. vij are
given every three hours. At the same time a teaspoonful of
cod-liver oil is given thrice daily, or if it disagrees with the
stomach, the ail is well rubbed into the skin once a day. As
a hygienic measure the child is thoroughly washed every day
with warm water and soap, and is clothed in flannels whids
cover the whole body,
EPB3TAXI&.
Ten-drop doses of Squibb's fluid extract of ergot are given
after meals with the same amount of the muriate of iron. This
treatment has been followed by excellent results in the warda
of Belle vue Hospital.
\,
DISINFECTANT AND ANTISEPTIC COUGH MIXTURE,
This is very much used at Bellevue Hospital.
R Potas. iod ,.^. ..._,. :jj.
Acid. nit. dil.... ^iij-
Tr. belladon fjjj.
Acid, salicyl .., ., j.
Aq. camph q. s. ad f^ iij. )f.
Sie. Two teaspoonfrjs in water three or four times daily.
SURGICAL AND VENEREAL DISEASES.
FISSURE OF THE RECTUM.
In young subjects, Dr. Erskine Mason keeps the bowels in
a soluble condition, and applies, locally, zinc or stramonium
ointment, in combination with belladonna or opium ; or ha
pencils the fissure to its bottom with a fine point of nitrate of
silver, or with nitric acid.
His radical method of treating this painful affection, con-
sists in dividing the mucous membrane and some of the fibres
of the sphincter muscle, with a knife, being careful to divide
the nerve filament involved. In some cases, he is able to
effect a cure simply by over-distension of the rectum. The
thumbs are introduced, back to back, into the rectum, when
forcible distension is made towards the tuber ischii, and car-
ried to the fullest extent possible. The cutting operation is
thus performed : the parts are put upon the stretch by intro-
ducing a speculum, and when they are moderately tense, the
knife is drawn through the base of the fissure. As after-
treatment, the patient is kept in bed for a day or so, and the
bowels are quieted by means of an opiate. Before the bow-
els are allowed to be moved, an enema of sweet oil is given.
LUXATION AT THE HIP- JOINT.
The patient is placed on his back, on the floor; the femur
is flexed upon t*he abdomen, until it is brought at right angles
with the pelvis; then, standing astride of the patient, the
assistant (Bellevue Hospital) clasps his hands under the legs,
close up to the thighs, and suspends the body. When the
(54)
Surgical and Venereal Diseases. 55
patient's body has been raised free from the floor, the sound
limb is so balanced against the leg of the surgeon that the
entire weight of the patient's body can be utilized as an
extending force upon the dislocated limb, and assisted, per-
haps, by a trifling rotation, will draw the acetabulum over the
head of the bone.
N.EVTJS.
Dr. R. W. Taylor employs the electric needle, for the pur-
pose of destroying these growths. Dr. A. C. Post believes
that if there is no tendency to spread, the nsevi had better be
let alone, but that, when they manifest a tendency to spread,
they should be at once removed. In this operation, he em-
ploys an instrument consisting of six needles, each about the
size of a fine knitting-needle, and without points. Thesw
needles are inserted in a handle, and, about half an inch from
their outer extremities, are passed through a bar containing
two rows of holes. Each row contains three needles, and the
perforations are separated nearly one-fourth of an inch in
each direction. By using this instrument, the operation is
greatly facilitated, and the heat is better retained in this bun-
dle than it would be in a single needle.
POTTS' DISEASE OF THE SPINE.
The plaster-of-paris dressing is thus applied at Bellevne
Hospital : the patient puts on a light wrapper, and then, by
means of a pulley attached to straps which pass through the
axillae and are secured to a cross-bar over the head, is com-
pletely suspended. In this way the weight of the body is
made to act as a counter-extending force, and removes all
pressure from the diseased surfaces of the bones. While thus
suspended, the wrapper is drawn down smoothly over the
trunk and hips. Then with a roller bandage filled with plas-
ter a beginning is made 2 or 3 inches below the crests of the
ilii, sufficient to secure a firm hold upon the pelvis. Two or
56 Notes of Hospital Practice.
three extra turns of the roller are first made at this point and
the body is then embraced by successive turns until the entire
trunk is encased to the arm-pits. If the disease is high up in
the dorsal region, the bandage is carried over each shoulder,
like a pair of suspenders. A roll of cotton is placed upon
each side of the spinal cord opposite the seat of disease. Two
or three rollers, supported by fine strips (made rough like a
grater to prevent them from slipping,) make a substantial
jacket. The cotton padding is not allowed to be excessive, as
it would thus obliterate the irregularities of the surface almost
entirely, which is just the thing to be avoided, for it is the
gentle moulding of the jacket to the depressions and elevations
of the surface of the body that enables it to accomplish its
work and be worn without complaint. When abscesses are
present, windows are made in the jacket through which they
can discharge.
STRICTURE.
Dr. H. B. Sands believes internal urethrotomy to be appli-
cable chiefly to close strictures and as an auxiliary to dilatation.
He is a firm believer in gradual dilatation as by far the best
method of treating the majority of strictures. He considers
the use of sounds exceeding 25 mm. to be very rarely neces-
sary either as a means of diagnosis or of treatment. The prac-
tice of slitting up the meatus he denounces as irrational.
Dr. F. N. Otis regards gradual dilatation as only a tem-
porary expedient. He does not think that section should be
limited to close strictures. In all cases he insists upon the
prompt restoration of the urethral calibre.
Dr. F. J. Bu instead regarded internal urethrotoray as pre-
ferable, to gradual dilatation in the treatment of stricture.
Some time ago he was in the habit of treating urethral stric-
tures by means of Holt's divulsor, but latterly and up to the
time of his death, he discarded this method of treatment
entirely. He found that internal urethrotomy was produclis r e
Surgical and Venereal Diseases. 57
of better results when carried to a considerable extent than
when more limited. In several cases he cut so as to admit a
35 or 40 mm. French scale. He thought that sounds larger
than 25 mm. were constantly needed in practice. He thought
that the meat us was slit up entirely too much, but he had never
seen any bad results follow such slitting.
Dr. E. % L. Keyes thinks' that internal urethrotomy is better
than dilatation in strictures situated in the anterior portion of
the urethra. In the treatment by dilatation he prefers instru-
ments below rather than above 30 mm. Strictures in the
deeper portions of the urethra he treats by gradual dilatation
and traumatic linear strictures by external section.
STRANGULATED AND INCARCERATED HERNIAS.
Dr. Frank Hastings Hamilton has reached the following
conclusions regarding posture in the treatment of strangulated
and incarcerated hernias:
1. Taxis is of prime importance.
2. Internal traction is only second to this in value. This
is accomplished by securing the paralysis of the abdominal
muscles ana exciting peristalsis in the intestines.
3. Chloroform, hot baths and other similar agents are the
best means for accomplishing muscular relaxation, peristalsis
and anti-peristalsis.
4. Ice can only relieve the "button-holing" when this is
due to congestion, and when it is applied very early. Opium
is also of a somewhat limited application.
5. Emetics are of service in causing an upheaval of the
viscera and in exciting peristalsis.
6. Purgatives act by causing peristalsis above, and anti-
peristalsis below, the seat of stricture.
7. Stimulating eneraata and enemata of tobacco also pro-
duce peristalsis, and are both direct and indirect in their
effects.
68 Notes of Hospital Practice.
8. All positions of the patient are beneficial in which the
viscera are drawn unwards ; and that is likely to be of the
most service which causes the most efficient inward traction,
at the same time that it does not interfere with the applica-
tion of taxis.
PROLAPSE OF THE RECTUM.
In recent cases, Dr. Abram Jacobi finds an injection of ice-
water sufficient to effect a cure. Where this fails, he resorts
to zinc or alum. He finds the nitrate of silver, either in stick
or solution of varying strength, an excellent remedy. In
whichever form used, its action is immediately neutralized.
Otherwise, it may give rise to extreme tenesmus. The actual
cautery is employed with good effect in some cases. When
there is only a paralysis of the sphincter ani, mix vomica or
strychnia are employed. He very often employs strychnia
hypodermically, using about 1/gQ of a grain every day. An
ointment which he very often uses is one composed of 3 j of
the alcoholic extract of nux vomica rubbed up with an ounce
of fat.
LIGATION OF THE LINGUAL ARTERY IN THE 'REMOVAL
OF CANCER OF THE TONGUE.
Dr. George F. Shrady reaches the following conclusions in
this connection :
1. Cancer of the tongue, whenever possible, should be re-
moved through the mouth.
2. Ligation of the lingual artery should always precede
this operation.
3. This ligation should be performed near the origin of the
vessel.
4. The use of the scissors and knife places the wound in a
condition more favorable for rapid healing than when the
ecraseur or any variety of cautery is used.
Surgical and Venereal Diseases. 59
5. Ligation of the lingual helps to prevent the return of
the disease.
8CIRRHUS OF THE MAMMA.
Dr. C. K. Briddon operates by the electrolytic plan of
treatment. A needle, attached to the negative pole of a
Drescher constant battery, is plunged into the tumor near its
base ; a sponge electrode attached to the positive pole is ap-
plied to the opposite side of the tumor, and the current from
ten cells set in action. No anaesthetic is used.
EXTIRPATION OF THE RECTUM FOR CANCER.
This operation is performed as follows, by Dr. Keyes :
The mucous membrane is incised from the tumor downwards,
and the incision carried, externally, through the skin only as
far as the tip of the coccyx. A stout needle and ligature,
carrying the wire of the ecraseur, are then passed from near
the tip of the coccyx, upwards, outside of the gut, above the
disease, then through the wall of the bowel and out at the
anus. The tissues included in the loop of the wire are then
slowly divided. The diseased portion of the gut is now
drawn well down, and stout knitting-needles are thrust
through the healthy tissue, beyond it, on each side, suc-
cessively. The loop of the ecraseur is then carried round,
above the needles, and the whole mass thus removed. No
antiseptics are used.
FIBROUS ANCHYLOSIS.
Inflammatory action is subdued, by Dr. Lewis A. Sayre, by
rest in bed and continued application of cold to the inflamed
parts by means of ice-bags. When inflammatory action is
subdued, the patient is placed upon an instrument consisting
of a pelvic belt, with perineal bands; a long bar, with a foot-
60 Notes of Hospital Practice.
piece and adjustment, for extension ; a knee-cap, and a mov-
able joint, opposite the hip, for flexion, extension and abduc-
tion. The movable joint is so arranged that abduction and
rotation of the limb outwards can be effected at the same
time. The most admirable effects have, in most cases, fol-
lowed the use of this apparatus.
CHRONIC SYNOVITIS.
Decided benefit has been obtained, in the sub-acute stage,
by pressure applied to the joints. This is accomplished by
means of a compressed sponge. The joint, which is the seat
of the disease, is covered with a compressed sponge, which is
retained in position by means of a roller bandage. The sponge
is then wet with warm water, which causes it to gradually ex-
pand, and thus produce an equal amount of pressure over all
the parts covered. The sponge is applied once or twice a day,
as the case may demand.
To remove the fluid, simple aspiration, followed by elastic
pressure, suffices in most cases, but where simple aspiration
does not succeed, Dr. Sayre removes the fluid by means of
the ordinary trocar, and then injects the cavity with Lugol's
solution of iodine. After this operation, the patient is placed
in bed, the knees firmly bandaged, locked in a perfectly
immovable apparatus, and elevated above the rest of the
body. Ice-bags are employed, if necessary, so as to keep
down inflammatory action.
This disease is treated at the Roosevelt Hospital by leeches
applied over the diseased joint.
CANCER OF THE LOWER LIP.
Dr. Sayre removes these growths at once, with a knife.
He avoids hemorrhage by having an assistant make pressure
upon the facial arteries, as they pass over the ramus of the
lower jaw. The wound is closed by means of sutures, or
Surgical and Venereal Diseases. 61
pins with the figure-of-eight suture. Pins are most frequently
used, and are passed through the lips of the wound, whose
edges are then brought together in such a manner as to avoid
leaving any notch in the free margin of the lip. The attach-
ments of the cheek are loosened with the knife, if necessary,
in order to give more opportunity for perfect adjustment.
Two pins have usually sufficed. After the pins are adjusted,
and the sutures twisted about them, a piece of adhesive plaster
is placed beneath the point of the pins, to prevent irritation
and excoriation. Then long, narrow strips of adhesive plas-
ter are adjusted so as to give support to the pins in holding
the lips of the wound in co-aptation. These strips, passing
above and below each pin, are carried far back upon the sides
of the face and neck. The pins are removed within 48 hours,
at most, after the operation. They are removed by seizing
them at the head with a pair of pincers and carefully turning
them round once or twice, before making the least traction.
In this way, the pins are withdrawn without disturbing the
threads or plasters, which, together with the crusts, are left
remaining, and are not removed for some time.
INGROWING TOE-NAILS.
Immense relief has been afforded in these cases, by Dr.
Sayre, by applying a few threads of cotton beneath the cut-
ting edge of the nail, in such a manner as to protect the
excessively-tender tissues from the irritation produced by
being brought into close contact with it. This cotton is
applied by means of a narrow, thin-bladed knife, without
cutting edge. With this instrument, he draws a few threads
of cotton down between the nail and the mass of granula-
tions, and so on until they are carried beneath the cutting
edge of the nail. After placing the threads in situ, the fung-
ous granulations are penciled over freely with nitrate of silver.
This application is repeated as often as the destroyed tissues
separate, until the exuberant growth is all destroyed.
62 Notes of Hospital Practice.
INFLAMMATION OF THE WRIST-JOINT.
The indications consisting in placing the joint perfectly at
rest, and at the same time removing all pressure from the
articular surfaces, Dr. Sayre proceeds as follows : He takes
a piece of sole-leather, long enough to half or two-thirds
surround the arm. This is then dipped in cold water, and
made thoroughly flexible. It is then covered with a piece of
adhesive plaster, plaster side out, long enough to go com-
pletely round it, lengthwise. Each opening is then covered
Avith a piece of oakum. The leather-lined plaster he now
applies to the palm of the hand, moulding it and securing it
with a roller bandage, as far as the wrist. Grasping the hand
already covered, while an assistant grasps the arm near the
elbow, he makes extension and counter-extension, until the
patient says that all pain is relieved, and then brings the
remainder of the leather- lined plaster against the forearm,
and secures it with a continuation of the bandage. In this
manner, all pressure is removed from the articular surfaces,
pain is relieved, and an apparatus is afforded which retains
everything at perfect rest.
FISTULA IN ANO.
Several cases of this disease have been treated in the wards
of the Roosevelt Hospital by means of the elastic ligature, and
the patients have suffered but little inconvenience while the
ligature was cutting through. They were up and about most
of the time, and suffered but little pain. In one case the
ligature cut its way through in five days; in two other cases,
in seven days, and in every case a fine granulating surface
was left behind, which healed much more readily and satisfac-
torily than the wound made by the knife.
EMPYEMA.
The treatment uursued at the Roosevelt Hospital, in cases
Surgical and Venereal Diseases. 63
of this disease, is by free incision through the chest wall. The
pleural cavity is then washed out with a solution of salicylic
acid, of the strength of 1 part to 500 of water. If the open-
ing shows a tendency to close at any time, it is dilated with
sponge-tents.
BORACIC ACID AS AN ANODYNE.
Pain in and about the wound, subsequent to removal of the
breast for scirrhus, is allayed, at St. Luke's Hospital, by ap-
plying cloths which have been wet in a solution of boracic
acid.
SILICATE OF LIME SPLINT.
This splint is obtained by using a saturated solution of
chloride of lime and the silicate of soda. It is supposed that
a chemical decomposition occurs between the two articles,
which gives rise to silicate of lime. The apparatus is made
in the following manner: First apply a bandage which has
been soaked in the solution of lime and then squeezed very
nearly dry ; next give the bandage applied a coating of silicate
of soda ; then apply another bandage wet in the lime solution
and follow it with a coating of the soda. Thus go on until
the requisite number of bandages are applied. The splint,
when dry, is much harder than the silicate of soda splint. It
is much lighter than a plaster splint, and has given general
satisfaction at Bellevue Hospital.
SURGICAL DRESSING.
The dressing has been found, at Bellevue Hospital, to be
a valuable one for all granulating surfaces.
R Baeilicon ointment %j.
Balsam of Peru jj. M.
SlCK Apply, spread upon lint.
64 Notes of Hospital Practice.
BURNS.
At Bellevue Hospital burns are coated with mucilage of
gum arable and are then dusted with lycopodium. As soon
as any of this dressing falls off it is re-applied. In other in-
stances, a solution of the nitrate of silver (gr. xx to the ounce)
is employed. In some cases, solutions as strong as gr. xl to
the ounce have been employed with benefit. The solution is
applied with a camel's-hair brush, and the surface is left ex-
posed to the influence of light and air. The solution is re-
newed whenever fissures occur in the coating thus formed.
ANTHRAX.
A very simple and efficient method of management has
been adopted at Bellevue Hospital. A broad piece of spongio-
piline is chosen and a hole cut through it large enough to
receive the apex of the tumor. It is then applied, and the
anthrax let alone.
ABSCESSES
At Bellevue Hospital are at first injected with a solution con-
sisting of equal parts of water and tincture of iodine. This
solution is gradually increased in strength until pure tincture
of iodine is employed.
t
INTERNAL HAEMORRHOIDS.
Dr. Erskine Mason divides treatment into medical ana
surgical. The aperients which he considers most valuable are
the salines in combination with sulphur, or a pill composed
of taraxacum and aloes.
As regards the employment of nitric acid, he thinks that
its use should be confined solely to those vascular spots of
mucous membrane which are sometimes seen in connection
Surgical and Venereal Diseases. 65
with other tumors, and to the small, florid, sessile growths,
which so readily bleed upon the slightest touch. The acid
which he employs in such cases is of the strongest kind. The
parts are dried and then touched lightly with a piece of wood
dipped in the acid, avoiding the surrounding mucous mem-
brane. The parts are then oiled and returned. One or two
applications generally suffice.
In some cases Dr. Mason employs the clamp and actual
cautery. He grasps the pile with forceps, or tenaculum,
drags it down, and strongly compresses it by means of a clamp
around its base. The pressure is maintained by means of a
screw. He then, with a pair of curved scissors, clips off the
pile, a short distance from the clamp, so as to leave a stump,
over which an iron heated to a dull heat is drawn.
He regards the ligature as the safest and most efficient
means of treating piles. He employs a moderately fine,
waxed, silk ligature, or one of linen. After seizing the
tumor and dragging it down, he surrounds it with the ligature,
ties it tightly in two knots, and cuts it off a little distance
from the knot. He is careful not to tie the ligature close up
to the base of the tumor, and so avoids including the coats of
the intestine and consequent troublesome contraction of the
bowels.
He regards with great favor Mr. Allingham's method of
treating internal hemorrhoids which consists in separating the
pile, with the scissors, from its attachment to the muscular
and other tissues of the bowel beneath its mucous membrane.
The cut is carried up for a little distance parallel to the wall
of the bowel and the neck of the tumor is then ligated. In
this way little more than the vessels which form it are tied
and there being less tissue for the ligature to separate, it comes
away sooner. The vessels running parallel to the incision are
not likely to be wounded, and if there is any bleeding point it
is readily seen and can be tied at once. The wound, being an
incised one, readily heals. After this operation the patient is
confined in bed for at least a week. Dr. Mason is in the habit
66 Notes of Hospital Practice.
not only of having the anus frequently bathed with warm
water, but also irrigates the parts with tepid water and a little
carbolic acid by means of a small syringe. Immediately after
the operation a pad of picked lint is placed over the anus and
held in position by a tight T bandage.
WET STRAPPING.
It is regarded at Bellevue Hospital as an item of some im-
portance in the treatment of old ulcers, such as are of specific
nature, found upon the lower extremities, that, if strapped, the
plaster should be permitted to remain as long as possible with-
out change. With this object in view several cases have been
dressed with what have been called wet straps, which are pre-
pared by passing strips of adhesive plaster through hot water
instead of heating them in the usual manner. In these instances
the water is also carbolized.
It seems quite certain that the ulcers heal more rapidly
under this plan of treatment than any which has been adopted,
and that the plaster does not get loose as quick as when heated
over a spirit lamp.
ECZEMA RUBRA.
A number of cases of this disease as occurring in the wards
of Bellevue Hospital have followed facial erysipelas, and, after
trying all the remedies ordinarily resorted to in the treatment
of this affection without benefiting the patient, tincture iodine
was painted over the entire surfaace. As a result, the disease
was in every way aggravated for one or two days, but when
the artificial irritation subsided, the change produced in tissues
by the iodine permitted the cases to go on to rapid and com-
plete recovery.
DOUBLE OOLLES' FRACTURES
Are dressed at Bellevue Hospital with straight board spliuta
Surgical and Venereal Diseases. 67
6 or 8 inches long, the anterior splint reaching down to the
joint, the posterior 1, 2 or 3 inches upon the dorsum of the
hand. These splints are then secured with roller bandage.
Passive motion is begun at the end of the third week.
THE TREATMENT OF FRACTURES AT THE NEW YORK
HOSPITAL,.
Cotles' Fracture. The Morris treatment is that generally
pursued. Two bandages, 3 inches in width and rather loosely
rolled, are placed on either surface of the forearm, over the
seat of fracture, and maintained in place by a broad strip of
adhesive plaster, making sufficient compression to keep the
fragments in position.
Fracture of the Patella. Tilford's strap-and-buckle appara-
tus is applied. After union has taken place an elastic knee-
cap is used.
Fractures of the Tibia and Fibula. The fracture-box is
first employed and followed by the plaster-of-paris bandage.
Fractures of the Femur are treated either with the plaster-
of-paris splint, or with Buck's extension apparatus, with Volk-
man's sliding contrivance for keeping the foot straight, and
ordinarily a long external splint.
EPIDIDYMITIS.
When a case of gonorrhoea presents itself at Bellevue Hos-
pital the patient is made to wear a suspensory bandage. This
bandage may prevent swelling of the testicle. When the
epididymitis occurs in spite of the bandage and is seen early,
if the pain is severe, needle punctures are made in the tunica
vaginalis, and the hydrocele, which causes the pain, thus
relieved. As a rule it has not been found advisable to use
urethral injections during the acute stage of epididymitis. In
this stage sedative lotions, fomentations, leeches, and cold
68 Notes of Hospital Practice.
applications are employed. Rest in bed is insisted upon. If
leeches are used they are applied along the course of the
spermatic cord. The testicles are supported by passing a
broad strip of adhesive plaster under the scrotum and from
one thigh to the other.
THE TRANSPLANTATION OP SKIN.
Dr. H. D. Noyes lays great stress upon the observance of
the following rules :
First. The piece of skin used must be dissected so as to be
entirely free from subcutaneous connective tissue and fat.
Second. The piece of skin should not be secured in position
by means of sutures, but by co-aptation with gold-beater's
skin, or such means as maintain absolute immobility during
the entire process of union.
Third. There must be expected an extraordinary contrac-
tion when the piece of skin is separated from its surroundings.
ACUTE, NON-SPECIFIC URETHRITIS.
Rest, and 30 grains of the citrate of potassium three times
a day, is the treatment generally pursued witli success by Dr.
Gouley.
PERINEAL FISTULA.
Firm pressure is made with the finger, placed either in the
rectum or at the point of the internal orifice of the fistula,
every time that the patient urinates, in order that the urine
may pass through the urethra, and none escape into the fistu-
lous tract. In this way, Dr. Gouley gives the fistula an oppor-
tunity of healing up by granulation, without having the pro-
cess interfered with by the passage of urine over the surface.
' '"Sv
CHANCRE.
When a well-determined initial lesion is situated in looso
Surgical and Venereal Diseases. 69
tissue, Dr. F. N. Otis excises it as early as possible. The
infective neoplasm he removes entire. He performs the opera-
tion of incision in the following manner: The parts are
first thoroughly cleansed by gentle bathing in warm water
In all open legions, a solution of carbolic acid, of the strength
of 1 part of the acid to 40 parts of water, is applied, after
which, the indurated mass is raised between the forefinger
and thumb, and encircled firmly at the base with a bit of fine
silver or malleable iron wire. Then, with a narrow, sharp-
pointed bistoury, the tissues are pierced at the centre, beneath
the compressing wire, or probe, and cut well under and out,
including all the indurated and a little of the sound tissue of
that side. The same cut-out is then made on the opposite
side. After every portion of the neoplasm is removed, inter-
rupted sutures of silk, or silver wire, are then introduced at
intervals of one-fourth of an inch. The patient is kept in
the recumbent position, the parts being occasionally wet with
carbolated water, until the third day, when union by first
intention, is usually found to have taken place.
When excision is unadvisable by reason of the location of
the indurated papule, it is subjected to applications of the
oleate of mercury (six per cent, solution), or a mild mercurial
ointment, is employed. When the mucous membrane cover-
ing the induration is abraded, it is dusted with dry calomel
and protected with a thin layer of dry lint. Calomel, in
combination with lime-water, in the proportion of a drachm
to a pint, or half a drachm of the bichloride of mercury, are
much esteemed by Dr. Otis as topical applications. Calomel,
in some form or other, is always administered internally.
The mucoid Chancre is treated by the application of the
solid nitrate of silver.
The inflamed, or suppurative initial lesion is treated by rest
and some sedative dressing such as the lotio plumbi et opii, in
a 5-grain solution, or the simple powdered iodoform, or iodo-
forin with an equal part of taunic acid.
The gangrenous form is managed by poultices of powdered
70 Notes of Hospital Practice.
charcoal, and by the internal administration of mercury
Where the patient is debilitated or scrofulous, generous diet,
quinia and iron are necessary.
Concealed initial lesions are treated with bougies or supposi-
tories, medicated with opium, salicylic acid, or iodoform.
THE CHANCROIDAL UL.CER.
Here are some formulae which Dr. Sturgis recommends for
local application :
1. R Pulv. iodoformi .......................................... 1 part.
Lycopodii .................................................. 2 parts. M.
Triturate well, apply locally.
2. R Pulv. iodoformi,
Pulv. acid tan ............................................. p. oe. M.
Triturate and use locally.
3. R Pulv. iodoformi .......................................... 5J.
Tinci sulphat ............................................. gr. v.
Pulv. acid, tan ............................................ ^ j. M.
Triturate. For local use.
4. R Acid, carbol. cryst
Aquae
Or,
5. R Zinci sulphat ............................................. gr. v-xx.
Aquae ........................................................ f ij. M.
6. R Acid, nitric! ............................................... f^ss.
Aquae
As agents destructive of the chancroidal ulcer Dr. Sturgis
employs (1) the white iron, or the galvano cautery, (2) strong
sulphuric acid, (3) chemically-pure nitric acid, (4) pure carbolic
acid. He very generally applies sulphuric acid in the shape
of Ricord's carbo-sulphuric paste, which is made by taking a
small quanity of finely-powdered tvillow charcoal, and enough
Swrgical and Venereal Diseases. 71
of the acid to make a paste of the consistence of thick cream.
This is put on with a porcelain or glass spatula, care being
taken to carry the agent into sound tissue both beneath and
on the surface of the edges of the chancroid.
Salicylic acid is first sprinkled over the sore at the New
York Hospital, and then the following wash applied :
\
R Acid salicyl.,
Sodii borat aa gr. xr.
Glycerinae ij^ j. M.
THE TREATMENT OF HEMORRHOIDS.
For the purpose of effecting a radical cure, piles are treated
at Bellevue Hospital with the double ligature. The sphincter
is not dilated. Treatment after the operation is believed to be
sufficient to prevent spasm of the sphincter. In cases in which
the pile can be easily surrounded, Sims' speculum is recom-
mended. The operation being completed, a suppository con-
taining opium and belladonna is introduced well above the
internal sphincter. A large piece of lint smeared with vase-
line is then placed over the anus and the cleft of the nates,
and the cleft packed with cotton until it is filled to a level with
the tuber ischii ; over that a compress is placed, and the whole
is retained in position by means of an ordinary T bandage.
But if hemorrhage occurs from the stump of the pile or else-
where, a plan of treatment is recommended, which although
not new, is perhaps worthy of description. Of course, effort
is made to tie the bleeding vessel. But the plan recommended
as the better one is first to take a cone-shaped piece of sponge,
and make it hollow ; then to pass a thread from the inside
through the side of the sponge, over the apex of the cone, and
return it to the cavity in the sponge. In that manner a loop
is made which places the sponge within the control of the sur-
geon. The sponge is to be slightly moistened, compressed, and
pushed up as high as possible in the rectum upon the tip of
72 Notes of Hospital Practice.
the finger. Pieces of lint are then carried in until the cavity
in the sponge is filled. As soon as filled, traction is made
upon the strings, when the sponge will spread out and press
against the sides of the rectum. In this manner the flow of
blood upward is prevented, and the compress already described
prevents any discharge from the anus. In ordinary cases it is
thought advisable to leave the sponge in situ for 36 or 48
hours. If hemorrhage returns, the sponge is replaced.
ACUTE RETENTION OF tJRINE.
A safe rule, therefore, for guidance HI the management of
cases of acute retention of urine of forty-eight hours' duration,
which Dr. Gouley lays down is, never to draw off more than
one-third of the contents of the bladder, and to do this very
slowly by half closing the distal end of the catheter, so that
the urine will flow m a very small stream. Having collected
half a pint, Ive closes the catheter for a quarter of an hour,
then lets another 'half pint flow, and so on, until the required
quantity has been obtained. In two hours he repeats the
catheterism, if the first has been easy otherwise, the catheter
is closed, and left in for tw<enty-four hours and removes
again the same quantity very gradually, and at the -expiration
of another period of two hours completely empties the blad-
der, always slowly; and in this way he takes the necessary
precautions to avoid 'both cystorrhagia and polynria. Every
three hours after the last catheteriara the urine is drawn off
until the patient can pass it spontaneously ; if he cannot do
so, the catheter is resorted to at such intervals as are found
necessary. Dr. Gouley also finds it necessary to treat the ex-
isting vesical inflammation and atony. For general medica-
tion he recommends the tincture of chloride-of iron, in 5-minim
doses, three times daily, and also diluent drinks, such as 30
grains of citrate of sodkim or potassium, in half a glass of
water three times daily, and in a few days, for a change, dog-
grass tea, etc. Topical-ly, kmsps 0f ice the size of the last joint
Surgical and Venereal Diseases. 73
of the thumb, are introduced into the rectum in rapid suc-
cession as fast as they melt, for an hour, night and morning.
A bag of ice is afterwards applied alternately to the perinseum
and hypogastrium for an hour or more. Each time that the
bladder is emptied by the catheter, a couple of ounces of cold
borax solution, from 5 to 10 grains to the ounce, are thrown
in ami allowed to run out slowly, then two more, and two
more ounces which are left in and the catheter withdrawn ;
this is accomplished in five minutes. Dr. Gouley has found
that no preparation gives more satisfaction than the borax so-
lution for cleansing bladders which contain offensive purulent
urine. He thinks it is as well to have in readiness a strong so-
lution of borax in glycerine ; 1 ounce of the biborate of sodium
being readily dissolved by 6 ounces of glycerine, each drachm
of such a solution being equal to 10 grains of biborate. In a
week, or thereabouts, if the case progresses well, the irriga-
tions are diminished in number until only one is used each
day. In some cases a mild faradic current has been found
serviceable
CYSTITIS FOLLOWING GONORRHOEA.
Dr. Gouley regards this as a very troublesome affection, and
one which is apt to last from three to six months. Some of
the French surgeons, he says, are in the habit of treating it by
injecting 5 or 10 minims of a solution of nitrate of silver, (30
or 40 grains to the ounce,) from time to time, into the blad-
der; but personally, he prefers the internal treatment by
means of diluents and balsamics. In addition, he thinks it
well to give belladonna, if the drug is well borne, and begins
with about J of a grain three times a day. In some cases,
even smaller doses than that have, in his hands, sent the
pulse up to 120, and produced the most uncomfortable symp-
toms, while other patients can take from 2 to 5 grains a day
with impunity. In some instances he is in the habit of com-
bining the aqueous extract of opium with the belladonna, (a
74 Note* of Hospital Practice.
grain of the one to of a grain of the other,) and sometime*
he finds that rectal suppositories containing these ingredients
act very admirably.
'CYSTORRHAGIA.
As a preventive treatment of cystorrhagia, and in cases of
over-distention of the bladder, Dr. J. W. S. Gouley teaches
that the bladder should be emptied very gradually in the
course of from 12 to 72 hours. This is accomplished by the
introduction of a soft catheter, which is secured in position,
and the urine then allowed to trickle through it slowly, by
partially obstructing the distal orifice with a finger, so that,
in the course of five or six minutes, not more than eight
ounces will have escaped. This process is repeated every two
hours, until the bladder is empty. If the urine drawn is
very foetid, the process is modified as follows: Immediately
after drawing the first half pint of urine, eight ounces of
warm water, in which has been dissolved a scruple of bibo-
rate of soda, are injected into the bladder, then a pint of urine
drawn, and immediately, half a pint of borax solution thrown
in. This procedure is repeated six or eight times, at the first
sitting, or until the whole of the offensive urine is gotten rid
of, and the bladder contains nothing but the clear borax solu-
tion ; then, every two hours, and in some cases, even every
three hours, half a pint of the fluid now mixed with newly-
secreted urine is drawn off, until the bladder is completely
empty. In this way, a bland fluid is substituted for decom-
posed and irritating urine, the hydrostatic pressure will not
have been removed too suddenly, and cystorrhagia is pre-
vented.
When cystorrhagia has taken place, besides enjoining abso-
lute rest, in the horizontal posture, Dr. Gouley takes means
to prevent the bladder from becoming distended with bloody
urine. If he finds hypogastric dullness extending to or into
the umbilical region, he draws off, through a gum catheter,
only a pint of urine, then throws in half a pint of the borax
Surgical and Venereal Diseases, 75
solution, and draws half a pint of fluid, and repeats the pro-
cess until the fluid becomes clear, or nearly so. Afterwards,
every hour or two hours, the stopper of the catheter is
removed, and half a pint of fluid allowed to flow, until the
Madder is completely empty. The catheter is retained in
position for 24 hours. The hemorrhage is checked by occa-
sionally throwing into the bladder two or three ounces of a
weak solution of tannin, or of alum. Dr. Gouley has also
found ice in the rectum a valuable adjuvant.
He treats hemorrhages caused by papillomatous or cancer-
ous tumors, by the exhibition of ergot, in the shape of from
"H^xv-xx of the fluid extract, given every two or three hours,
or else he uses gallic acid dissolved in glycerine, or quinia
with an equal quantity of dilute sulphuric acid, or tincture
of the chloride of iron, etc. The dose is reduced and alto-
gether discontinued, as SOOD as possible, so as to save the
digestive organs.
When no fluid runs through the catheter, after it has been
properly introduced, owing to the fact that a clot has become
impacted in the catheter, Dr. Gouley removes the catheter
and washes it out, or takes a clean catheter and introduces it.
But when the bladder is filled with clotted blood, he uses a
soft catheter, with one large eye, or a metallic Mercier cathe-
ter, as large as can be introduced, and iiyects one or two
ounces of warm borax .solution. If nothing flows, the instru-
ment is moved gently to and fro, and rotated to the right and
left, so as to break up the clots. Aspiration is then made,
either with a syringe or with Bigelow's rubber bag. Not
more than three or four ounces of clots, or gmmous clots, are
aspirated at a time. Alternate injections and aspirations are
made at the same sitting.
THE MEDICAL AND SURGICAL DISEASES OF
WOMEN.
VAGINISMUS.
Dr. T. G. Thomas treats this condition as follows : First,
the patient is thoroughly anaesthetized with ether, and then
*>ach labium majus is held back by an assistant. The parts
being thus exposed, the hymen is seized with a pair of mouse-
toothed forceps, and snipped completely out with the scissors,
which are preferable to the knife for this purpose. The
sponge is usually all that is necessary to stop the bleeding.
The entrance of the vagina is then cut down upon and en-
larged, and while this is being done the assistants are instructed
to stretch the vagina well on either side. The incisions are
made into the perinaBal body, but not through any muscle.
Three incisions are all that Dr. Thomas finds necessary. Of
these, one is in the median line, and one on either side. One
of Sims' plugs is then pushed into the vagina and held in
place by means of a broad strip of adhesive plaster passing
from the lower part of the back, over the perinseum and up to
the abdomen, with a hole cut in it for passing a catheter.
The plug puts an end to all hemorrhage, and is generally left
in position for three or four days before being disturbed. At
the end of that time, it is taken out so as to permit the vagina
to be thoroughly syringed with warm water. It is then re-
placed as before. In a week's time the patient is able to re-
move it and put it back herself. It is to be worn for three
weeks or more constantly, then it is only necessary to wear it
at night. In the course of a month or six weeks, Dr. Thomas'
patients are able to dispense with it altogether.
(76)
Medical and Surgical Diseases of Women. 77
LABOR IN KYPHOTIC PELVES.
Dr. Isaac E. Taylor reaches the following conclusions:
1. A mutilated child can be delivered with safety to the
mother through a space of If inches antero-posterior, and 2J
to 3 inches transverse diameter, by craniotomy, cephalotripsy,
or cranioclasm. When the vault has been destroyed, the face
is made to present edgewise, or the head gidewise.
2. After cephalotripsy, or cranioclasm, if necessary, version
with propulsion from above the pubes, performed early and
before the uterine forces are exhausted, is preferable to that
just indicated.
3. The cephalotribe, or cranioclast, cannot be considered as
available tractors in cases of extreme contraction of the pelvis,
but other instruments become necessary to properly eflect the
delivery of the woman.
3. The Caesarean section should not be performed when con-
traction or deformity is present, as stated above, unless de-
manded by other conditions and complications.
LACERATION OF THE PERINEUM.
Dr. Montrose A. Fallen urges immediate~~operative inter-
ference, if possible. He enters iiis sutures (silver wire) deep,
and not more than a line apart, and supplements them by
superficial sutures in each inter-space. The bowels are kept
soluble by warm enemata, and not constipated by opium, after
the common rule. The vagina is kept thoroughly cleansed,
the bladder well emptied, and the nates of the patient are
placed in an india-rubber ring cushion filled with air.
MENORRHAGIA.
Dr. Barker directs his patients to use for a week previous
to the expected period, the following suppositories:
78 Notes of Hospital Practice.
R Ext. ergot, aq. (Squibb) 9ij.
Cacao butter jj. M.
Et in suppos. No. xij div.
SlG. One to be introduced into the rectum morning, noon and night.
These suppositories are carried as far as possible up into the
bowel, and the patient directed to remain in a recumbent posi-
tion for at least an hour after using them.
In cases of irregular uterine hemorrhage seen in connection
with the climacteric period he introduces into the cavity of the
uterus cylinders of iodoform made according to this formula :
R Iodoform
Gum tragacanth gr. xv.
Mucil q. s. M.
Et div. into cylinders No. x, each one and one-half inches in length.
One of these cylinders is directed to be carried completely
into the cavity of the uterus, and a pledget of cotton is placed
against the cervix to retain it in position. One of these cylin-
ders is introduced daily for five or six days previous to men-
struation.
POST-PARTUM HEMORRHAGE.
When this is due to inertia of the uterus, Dr. Montrose A.
r*allen introduces the hand into the cavity and removes the
clot, then incites contractions of the organ by manual pressure,
and administers stimulants and ergot hypodermically.
Where consequent to laceration of the cervix uteri, the tampoh
is used and stitches are necessary.
PRURITUS VULVJE DUE TO VAGINAL LEUCORRHCEA.
Dr. Thomas recommends frequent vaginal injections of the
biborate of sodium in solution, and once or twice a week he
cleanses the cervix thoroughly of mucus and applies the
nitrate of silver. Occasionally he uses chemically-pure nitric
Medical and Surgical Diseases of Women. 79
moid with the hope of altering the secretion. Copious injec-
tions of water are continually used and the patient is told to
press a suppository of butter of cacao containing 5 grains of
tannic or gallic acid up against the cervix twice daily.
ABDOMINAL PREGNANCY.
Dr. T. G. Thomas lays down the following rules for the
management of cases of abdominal pregnancy :
1. Before full term, if the child is alive, its growth may be
carefully watched with the hope of delivering a living child
at the end of the ninth month by the operation of leparotomy
and also of saving the life of the mother.
2. If the child dies early in abdominal pregnancy, delay is
advisable, but it should not be carried to the extent of the
development of hectic and septicaemia.
3. At full term the best rule is to await the evidence of
constitutional disturbance, and then meet its development
promptly by operative interference.
Dr. Fordyce Barker lays great stress (1) upon leaving the
placenta in situ after the operation, and (2) upon subsequent
antiseptic treatment.
LACERATION OF THE CERVIX UTERT.
Dr. Gillette has recently resorted to a somewhat novel me-
thod of treating this condition. He seizes the torn cervix with
two tenacula, draws the lacerated surfaces together, and then
slips over the handles of the tenacula and around the cervix
an ordinary rubber strap. This treatment is not applicable
of course, to recent lacerations, since in such cases the band
constringing the cervix would prevent the discharge of the
Jochia.
8UBMUCOU8 AND INTERSTITIAL FIBROIDS OF THE WOMB.
Dr. Thomas believes that enuoleation and the use cf ergot
80 Notes of Hospital Practice,
are attended by the great dangers of septicaemia, peritonitis,
hemorrhage and exhaustion. He is, on the other hand, con-
viivced that a policy of inactivity is by no means always a safe
one. He thinks that the various other methods of treatment
employed at the present day, excision, torsion, avulsion, ecrase-
ment, and the production of sloughing are none of them with-
out objection, and offers in their place the following method,
which consists in seizing the most dependent and accessible
part of the tumor with a strong Volsella forceps, passing along
its sides the serrated scoop or spoon-saw, and by a gentle pen-
dulum motion from side to side, sawing through the attach-
ments of the tumor and forcing it entirely from its connection
with the uterus.
He claims the following advantages for the instrument :
1. The attachments are separated by a saw which greatly
limits hemorrhage.
2. The shape of the spoon, convex without and concave
within, causes it to follow, of its own accord, the contour of
the tumor and at the same time to protect the uterine tissue.
3. The highest attachment can be as readily reached as the
lowest.
4. The saw action secures separation with rapidity and with
certainty.
5. The spoon-saw secures separation of the growth at its
highest point of attachment, and leaves no particle to decom-
pose.
In order to determine the extent of the attachment of a
tumor, Dr. Thomas uses &flai ickalebone sound. He uses this
instrument in this way : the index finger of the left hand is
placed against the most accessible part of the tumor, and then
the sound is passed up along the side of the tumor until it is
arrested. The sound being then withdrawn with the finger
Btill upon it, is laid upon a sheet of paper, and beitig curved,
a line is drawn from its tip to the point touched by the finger.
The same is done for the opposite side of the tumor.
In the delivery of large tumors from the vagina, after their
Medical and Surgical Diseases of Women. 81
expulsion from the uterus, he recommends the following pro
cedures :
1. Seize the tumor with a strong forceps, draw it down,
sever the distended perinseum to the sphincter ani, partially or
completely invert the uterus, detach the tumor by means of
the spoon-saw, replace the uterus at once, and close the peri-
nseum by sutures.
2. Successive sections of the tumor may be cut away by
means of the galvano-caustic wire.
3. A large trocar and canula, or the actual cautery, or the
trephine obstetric perforator, may be used to channel up the
middle of the tumor, and then, with a strong pair of scissors,
or with the osteotome, pieces can be cut out, and the tumor so
diminished in size that it is susceptible of delivery.
Dr. Alfred Post finds much advantage arising from passing
a strong ligature through the part of a large tumor whieh
projects from the vagina. This is a more powerful means of
making traction than by the use of the Volsella forceps alone.
In the removal of large tumors which have been driven
into the vagina, Dr. Thomas Addis Emmet does not divide
the perinseum or enter the uterine canal, at all. He believes
that the fact that such tumors are in the vagina, shows that
the uterus is strong enough to drive them completely out.
ABORTION.
Dr. W. T. Lusk thus summarizes his views on this sub-
ject:
1. In the first two months, an abortion needs no special
treatment. The hemorrhages of early date are amenable to
the same principles of treatment as those from the non-preg-
nant uterus.
2. In the third month, no treatment is required, when the
ovum is expelled with intact membranes. When the mem-
branes rupture previous to expulsion, and .hemorrhage takes
82 Notes of Hospital Practice,
place, immediate removal should be attempted, provided that
the cervix be sufficiently dilated to admit the index finger.
When the cervix is closed, the tampon should be tried for 24
hours. If the tampon proves ineffective, the cervix should
then be dilated with a S{x>nge-tent, and the ovum removed
with the finger. The finger should be made to pass up along
the side of the uterus, across the fundus, and so complete the
circuit of the uterine cavity.
3. In cases of neglected abortion, retained portions should
be removed by the finger or the curette. When the ovum is
decomposed, no dilation of the os is usually needed. When
the ovum is fresh, the preliminary use of sponge-tents is usu-
ally demanded, if manual delivery is resorted to.
4. Fibrinous polypi, wlven situated near the os internum,
arrest the involution of the lower portion of the uterus. The
os is therefore open, and permits the passage of the finger.
When the polypus is attached to the fundus, the cervix is
usually closed. Small, smooth, slippery bodies, like fibriuous
polypi, are rarely to be detached, unless the finger operates
from above so that the choice of hands depends upon the side
to which the polypus is attached.
5. In immature deliveries, hemorrhage can usually be con-
trolled without the tampon, by compression of the uterus, and,
in cases of delay, by the manual extraction of the placenta.
Dr. Fordyce Barker believes that, occasionally, treatment
is required in abortion occurring in the first two months of
pregnancy. In these early abortions, he is accustomed to
inject into the vagina a very large quantity of very hot water,
from 104-110 F. He is sure that this will absolutely
arrest the hemorrhage.
In cases of abortion where it is necsssary to tampon, he
docs not trust to any kind of vaginal tampon, but always
plugs up the cervix uteri with a compressed sponge- tent, and
then only fills up the vagina sufficiently to keep this sponge
in place.
Medical and Surgical Diseases of Women. 83
8OHE NIPPLES.
Dr. F. V. White is in the habit of simply protecting the
nipple with an ordinary nipple-glass, secured in position by
means of a bandage.
Dr. S. S. Purple uses the following :
R Taania .................................. ............ ------- 3J.
Syr. acaeiie ...... ....................... ... ...... ..... ________ .. f^ij.
Aquae-...- ................ ..... .... ---------- .. ...... .,<. f g. M.
This is applied to the nipple and breast with the finger,
and allowed to remain exposed to the air .until perfectly dry.
Dr. Compton uses this formula.:
H Tr. benaoin. co.,
^^............^......^*...^..5a.. s. M.
OVASIOTOMY..
If the operation an be safely delayed for a week or more,
after coming under treatment, Dr. Nathan Bozeman prepares
the patient by administering to her tonics and food as much
as she can bear. Iron he considers a naest valuable agent in
the preparatory stage of ihe treatraen t. The an tiseptie method
(Lister's) l>e invariably uses in this, as in all major operations.
He thinks his successes are greatly due te the means thus
adopted of preventing peritonitis and septicaemia. Whether
long or short, he returns the pedicle into the peritoneal cavity,
after transfixing and tying it, right and left, several times
with waxed, carbolized, strong silk ligatures, and claims that
there is no necessity of using clamps or Koeberle's serre-nseud.
He includes the peritoneum in his sutures when closing the
abdominal incision, which he never makes larger than is neces-
sary in the median line, Oarbolized silk sutures are also used
for closing the wound as for tying the pedicle. .Beef tea, milk
and eggs constitute the food given as soon as the patient has
fully recovered from the anaesthetic, (ether being used for this
8 i Notes of Hospital Practice.
puiyose.) If there is a tendency to vomiting, the food is ad-
ministered per rectum. Quinine and opium the doctor con-
siders of the highest importance in the after-treatment, given
in full doses, as being antiperiodic, and a preventive of peri-
tonitis. Should there be an undue elevation of temperature,
not controlled by the medication enumerated, Kibbe's cot
comes into requisition. The first incision he never makes
larger than is necessary for the introduction into the peritoneal
cavity of his abdominal spatula, as the doctor terms it, (a
flexible, metallic rod, 10 to 12 inches long, well rounded off,
with a triangular-shaped termination at either end, like Nott's
vaginal depressor,) about one inch long, also well rounded
off. The size of the tumor, its adhesions, if there be any, are
thus explored with the aid of this spatula. The incision is
then enlarged to 4-6", for the purpose of introducing the
hand and separating the adhesions, if their presence has been
made out, in the mode above described. The next step con-
feists in tapping the cyst or cysts with Spencer Wells' trocar.
In multilocular cysts he taps one cyst after the other, through
the opening made in the first cyst, and so on, the patient
being turned on her side. The cysts are thus emptied to a
size sufficient to pass his right hand through the abdominal
opening into the peritoneal cavity while drawing out the cyst
or cysts with his left. This simultaneous use of both hands
Dr. Bozeman considers of the utmost importance while draw-
ing out the cyst. The right . hand introduced inside the
cavity completes the separation of adhesions that may have
remained after the use of his spatula, and also guards against
any undue stretching or possible rupture of the intestines,
gall-bladder, etc., with which there may be adhesions. The
omission of this precautionary measure doubtless has caused
many fatal results that might have terminated favorably had
this precaution been practiced. Six to 8 grains of quiniae sul-
phate, and 25 drops of the liquor opii comp., administered per
rectum, are the doses of these remedies used from the first for
the purposes mentioned. The use of hypoderniJc injections is
Medical and Surgical Diseases of Women. 85
avoided by Dr. Bozeman. After ovariotomy, he is of the
opinion that on account of the pain thereby produced, the
patients abhor them, and thus cause undue nervous excite-
ment. Dr. Bozeman never uses drainage tubes through
Douglas' cul-de-sac, but prefers to draw off effusions by means
of tubes introduced through the abdominal opening, reaching
down to Douglas' cul-de-sac.
To control the high temperature occurring after ovariotomy,
Dr. T. G. Thomas recommends the use of " Kibbe'-s fever-
cot." This cot consists of a strong, elastic, cotton netting,
manufactured for the purpose, tlirough which water readily
passes to the rubber cloth below, which is so adjusted as to
direct the stream into a vessel at the foot of the bed. His
method of managing his patients is as follows: He places
upon the cot a blanket or sheet, which is kept constantly wet
by pouring cold water upon it. The temperature is taken
every hour ; bottles of warm water are applied to the feet and
hands; the patient is allowed to remain upon the cot as long
as necessary, constantly enveloped in the wet sheet, and con-
stantly exposed to the influence of cold water. The ur-ine is
drawn with a catheter, and a bed-pan is used. His aim is to
keep the temperature of the body at 100 F., or a little less.
PUERPERAL CONVULSIONS.
Dr. S. T. Hubbard lays down the following rules: (1) gen-
eral blood-letting is called for when headache continues after
labor is completed, and is attended by flushed face, restlessness
and convulsions of atonic character. Particularly is this pro-
cedure demanded when there has not been much loss of blood
at the birth of the child ; (2) that the infusion of digitalis is
useful to steady the heart's action, to allay nervous irritation,
and also as a diuretic when aided by the addition of the bitar-
trate of potassium ; (3) that chloroform ought to be used spar-
ingly; (4) that the continuous action of chloral hydrate is
greater than that of chloroform and that k is less likely to
86 Notes of Hospital Practice.
disturb the brain ; (5) that in cases in which there has been
great loss of blood, or great prostration attended by nervou*
exhaustion, dependence may be placed upon hypodermic injec
tions of morphia for controlling the convulsions.
AMENORRCEA FROM ANJEMIA.
Dr. A. J. C. Skene aims first at restoring the normal con-
dition of the blood, and second, at re-establishing menstrua-
tion. Capricious appetite, coated tongue, and constipation he
overcomes by giving at the outset a cathartic pill composed of
pil. hydrarg. rubbed up with glycerine, syrup, rhei aromat
and carbonate of magnesia. If the constipation is obstinate,
the following prescription is used :
fit Quinise sulph.,
Ferri sulph aa ^ij.
Ex. colocynth. comp gr. x.
Ex. belladon gr. ijss. M.
Sio. One pill before each meal.
If advisable, aloes is substituted in place of the colocynth.
Among ferruginous tonics Dr. Skene prefers the chlorate of
potassium combined with the tincture of the chloride of iron.
He also recommends a small quantity of wine or alcohol after
meals.
When amenorrhoea persists after the anaemia has been cured,
he gives 5-grain doses of the chloride of ammonium every 3
or 4 hours. He believes that this drug favors the rapid ex-
foliation of the epithelial lining of the endometrium. Dr.
Skene is opposed to the employment of emmenogogues in this
condition, holding that they almost all act by producing irri-
tation and congestion of the pelvic organs.
KETROFLEXION OF THE UTERUS WITH HYPERJ3MIA.
One of Dr. Bozeman's patients had been subject to uterine
Medical and Surgical Diseases of Women. 87
aemorrhage more or less severe and frequent, and the fundus
had been in such a hyperaemic condition, that the slightest
touch of the probe was followed by quite a free flow of blood.
This engorgement was treated with applications of a solution
of carbolic acid in glycerine, of the strength of half a drachm
to the ounce, and also by the frequent use of hot vaginal
douches. Under this course of treatment, decided improve-
ment had taken place, notwithstanding the fact that it was as
yet impossible to restore the uterus to its normal position. A
little later it was proposed to accomplish this restoration by
gradual pressure upon the vagina and the fundus uteri bj
means of the persistent use, for a sufficient length of time, of
cotton columns applied in the vagina, in accordance with the
method that has proved so successful in Dr. Bozeman's hands.
The plan is original with him, and is somewhat as follows :
The patient having been placed in the knee-elbow position,
and Bozeman's speculum introduced, a pledget of carbolized
cotton is pushed up against the fundus with a pair of dressing-
forceps, and held in position there by means of the perineal
elevator ordinarily employed in connection with this speculum.
A second and third pledget is then applied in the same man-
ner, the perineal elevator being drawn a little further out as
each is introduced ; and this process is carried on until a firm
column of cotton, not stuffing up the whole vagina, but of
comparatively narrow diameter, has been formed that reaches
obliquely from the fundus of the uterus to the symphysis
pubis, which is here the point d'appui. Such a column may
ordinarily be left in position for about 2 days, but is not
allowed to remain for longer than 48 hours. These columns
are put in about every three days, the patient being allowed
to rest for 24 hours after the removal of each one, and vaginal
douches being used in the interval. When by this means the
uterus has been restored to its normal position and the vagina
to its normal condition, any appropriate support may be worn
by the patient as long as is necessary.
88 Notes of Hospital Practice.
TREATMENT OF TYMPANITES.
In some instances, Dr. T. G. Thomas finds systematic
kneading of the abdomen to be of service, and that the knee-
chest position will often enable the patient to get rid of a con-
siderable quantity of the gas. There is one case which he
mentions particularly, in which such marked tympanites came
on after ovariotomy that the patient nearly died in consequence
of it. When this method was resorted to, there was an escape
of an unlimited amount of flatus by the anus, and the patient
afterwards made a good recovery from the operation.
CHRONIC OVARITIS.
Dr. T. G. Thomas holds that the patient needs feeding up
to the greatest possible extent, in addition to a course of ap-
propriate tonics. One of the best of these, in this condition,
is the syrup of the hypophosphites, which is now so frequently
employed in the incipient stages of phthisis. The remedies
employed are changed from time to time. He has found no
other treatment for chronic ovaritis nearly so good as change
of air and scene, and the pleasurable excitement of sight-
seeing and travel in cheerful company, although he does not
pretend to explain exactly in what manner the good result is
brought about.
But if the patient is not able to travel in Europe, she is
directed to make use of very copious hot water vaginal injec-
tions at least twice a day, and three times, if possible. Then
the roof of the pelvis is painted once a week with compound
tincture of iodine. Iodine is also applied externally, and as
often as two or three times a week. At tiie same time, elec-
tricity is faithfully employed, and for this purpose, Dr.
Thomas has found the constant current the only one that is
of service, the faradic current being rather injurious than
beneficial. The best way to apply it, he thiuks, is for the
patient to lie upon one electrode while the other is carried to
Medical and Surgical Diseases of Women. 89
the region of the affected ovary, and the application may be
made once or twice a week. For at least a week preceding
menstruation absolute rest in bed is insisted upon, (rest being
as important to an inflamed ovary as to an inflamed eye ;) but
she is permitted to get up as soon as the flow makes its ap-
pearance.
KETROFLEXION WITH FISSURES AND STRICTURES OF THE
RECTUM.
The proper treatment in these cases, according to Dr. M. A.
Fallen, consists in keeping the bowels well open by enemata.
In addition to these, the woman is daily put in the geuu-pec-
toral position and her uterus thrown well forward until it gets
into a position in which it can be retained by a pessary. Such
patients as these are naturally and habitually constipated, the
toleration of the rectum being really wonderful.
Dr. Fallen teaches that another very excellent treatment of
these cases is by filling the rectum with very large quantities
of hot water, (as the bowel can be educated to be very tolerant,)
thereby unfolding the rugae, or rather expanding them, so that
the very bottom of the rugous fissures can be washed out, and
any mucosities or pus cleansed therefrom. After the gut is
thoroughly washed and the mucous membrane freed from
hyperseeretion, he considers it proper to touch the eroded or
ulcerated spots with nitric acid, nitrate of silver, or even the
milder non-caustic astringents. This he easily accomplishes
by dilating the rectum with the Sims speculum. But all treat-
ment is useless, if the physician fails to overcome the cause,
i. e., to get rid of retroflexion, for the fundus of the uterus
jams the anterior upon the posterior wall of the rectum, as
the hyperfemia produced by this, as well as the accumulated
faeces above, gives rise to rectal catarrh. Dr. Fallen claims
that in many cases of this character, an apparent stricture
ensues which is in reality no stricture at all, but is a symptom
90 Notes of Hospital Practice.
of obstruction, giving rise to the very distressing conditions of
the rectal tenesmus and dysenteric discharges.
, LEUCORRHOEA.
Due to Fungoid Growths on the Endrometrium. Dr. T. G.
Thomas treats this condition by passing a curette np to the
fundus, either after or before dilatation of the cervix, and
drawing it gently over both walls of the uterus. After this
he keeps the patient quietly in bed for from 2 to 3 days,
watching for the occurrence of pain, or increase of tempera-
ture. He then supports the womb by the introduction of a
pessary, and administers either viscum album in the form of
a fluid extract, or 20-drop doses of Squibb's ergot 3 times a
day.
Due to Insufficient Diet and Consequent Nervous Depression.
Dr. Thomas insists upon it that such patients eat fresh meat
3 times a day, together with other food, and that they take a
tumblerful of fresh milk between meals. At the same time
iron, bitter tonics, and beer or ale are ordered.
Due to the Presence of a Cervical Polypus. The leucorrhoea
will disappear as soon as the polypus is snipped off with the
scissors. Dr. Thomas lays great stress upon surgery as an
element of gynaecology.
Due to Ectropion of the Lining Membrane of the Womb.
Dr. Thomas cures these cases by snipping this ectropion on
both sides and turning in the edges of the mucous membrane.
He keeps the vaginal walls contracted by the use of astringent
vaginal injections.
CHRONIC UTERINE CATARRH.
The first thing done by Dr. Thomas is to put the uterus in
its proper position if it be displaced. It is then kept in place
by means of an anteversion pessary, and vaginal injections ar<
Medical and Surgical Diseases of Women. 91
employed constantly to keep the parts free from irritation.
After the next succeeding menstrual period the endometrium
is carefully and thoroughly scraped with the curette and all
the fungoid growths removed.
CARCINOMA UTERI.
Dr. Thomas, in cases which are destined to be fatal, aims
(1) at controlling the hemorrhage, (2) at relieving the pain,
and (3) at disinfecting the offensive discharges. The plan
which he pursues is as follows : first, he rapidly cleanses the
vagina aud uterine cavity by means of absorbent cotton, and
then applies chemically-pure nitric acid to all the diseased
surface. This generally controls the hemorrhage for a longer
or shorter period.
For the relief of pain his treatment is all summed up in
one word, and that is opium. If it does not suit the patient's
stomach it is given by the rectum or hypodermically.
He overcomes the disagreeable odor of the discharges by
means of very copious vaginal injections given 3 times a day,
and consisting of water containing a sufficient amount of
thymol or carbolic acid to act as a disinfectant, and some such
simple astringent as alum or sulphate of zinc.
As much food is required in such cases as can possibly be
digested by the patient. Dr. Thomas considers iron and the
hypophosphites as utterly useless. He regards milk as the
best article of food, 6 ounces being given at first every 3 hours
and afterwards every 2 hours. As soon as practicable a large
amount of cream is added, so that the- patient may take 2 ounces
of cream to every 4 ounces of milk. In this way he has been
able to prolong life for a considerable period in several in-
stances.
PUERPERAL PERITONITIS.
The opium treatment is employed by Dr. Clark in case?
92 Notes of Hospital Practice.
where peritonitis is the most prominent element. In Bellevue
Hospital five out of six are cured by this treatment. Besides
the opium, his patients take a few doses of veratrum viride to
diminish the frequency of pulse. He gives Norwood's mix-
ture of veratrum in d6ses of gtt. v, when the opium has re-
duced respiration but not the pulse. It sometimes produces
great nausea, attended by prostration and a tendency to syncope.
Alcoholics are used when such effects are produced. He con-
siders it a very good treatment to give opium and veratrum
viride in alternate doses, and regards this as all that is neces-
sary. In metro-peritonitis opium does not serve any import-
ant purpose, and he thinks it useless to give it, except to soothe
the patient. Leeches to the vulva or perinseum and bleeding
are very necessary. He very often employs injections of
warm and tepid water into vagina and uterus. During the
period of purulent infection, he prescribes quinia sulph., (gr.
xv per day,) combined with morph. sulph., to reduce irrita-
bility. If there is a tendency to the formation of abscesses,
food and stimulants are, of course, necessary.
VESICO-UTERINE FISTULA.
Dr. Bozeman's operation for the cure of this condition, con-
sists in the complete excision of the anterior lip of the cervix
uteri, together with a part of the vesico- vaginal septum, thus
converting the original lesion into a vesico-utero vaginal
fistula. This being done, the posterior lip of the opening,
which was the stump of the cervix uteri, is next pared off, as
is generally done in fistulae of the latter class. Four silver-
wire sutures are needed, which are introduced by a straight
needle set in a curved needle- holder. This being done, the
sutures are next adjusted in the usual manner, and a button
or plate of lead of suitable form and size, is slid down upon
them, and the whole then secured in place by the compression
upon each wire of a perforated shot. The great utility claimed
for this form of suture in the operation centres in the leaden
Medical and Surgical Diseases of Women. 93
plate, which stands across the cervical canal and prevents its
recontraction and the consequent puckering of the line of co-
aptated edges, until union takes place. After washing out
the bladder, the patient is placed in bed and quinise sulph.
gr. x, and liq. opii cornp. f 3 j., administered per rectum, and
followed by gr. j of opium by the mouth, every six hours.
Dr. Bozeman claims great advantage in the operation from
the use of the self-sustaining and dilating speculum. By
means of it the vagina is expanded to the fullest extent, and
the greatest facility afforded to the movements of instruments.
The advantages of the knee-chest position are also fully illus-
trated. The patient, resting upon a supporting apparatus,
takes the anaesthetic with the greatest comfort
NERVOUS DISEASES.
SPEEMATOERHCEA.
Constipation. An enema of cold water is ordered every
morning. This not only produces a normal evacuation, but
also stimulates the blood-vessels and the surrounding parts to
a more vigorous contraction and accelerates their return to a
normal condition.
Derangement of Digestion. A diet is recommended by Dr.
Joseph W. Howe calculated to increase the patient's vitality,
and consisting of oysters, eggs, milk, beef, mutton, etc.
Stimulants. Some mild wine, such as claret, is prescribed,
which will promote good digestion without exciting inordinate
desires.
Bathing. The patient is directed to take a cold sponge-
bath every morning. Cold water is, at the same time, ordered
to be thrown into the rectum.
Exercise of all kinds is advised, with the exception of horse-
back riding.
Local Treatment. Dr. Howe does not recommend caustics
or the passage of the sound, but thinks very highly of elec-
tricity. One electrode is insulated to nearly its entire extent,
except that part which rests against the prostatic urethra.
The other electrode is applied over the fourth lumbar verte-
bra. Only a very feeble current is allowed to pass through
at first, and the first sitting only lasts five minutes. The
second day, the wire-brush is used, passing it over the inside
of the thighs, about the perinseum. On the third day, the
urethral electrode is again employed. The strength of the
current is gradually increased with each sitting.
Medical Treatment. One of the best tonics, in Dr. Howe's
opinion, is this :
(94)
Nervous Diseases. 95
R Strych. sulph gr. j.
Quin. sulph gss.
Tc. ferri mur f ss.
Glycerines f J iv. M.
SIG. One-half teaspoonful in a wineglass of water, four times a day,
half an hour before meals, and at bedtime.
This is another favorite prescription :
R Ferri arsen.,
Ex. nuc. vom aa gr. v
Ergot.,
Quin. sulph aa 88. M.
Et in pil. No. xxx div.
SiG. One pill four times a day.
Where constipation is a prominent symptom, gr. x of aloes
are substituted for ergot, in the above.
Impotence :
R Ex nuc. vom. gr. I.
Phosphor gr. ^fa. M.
SIG. To be taken after meals.
In some cases, f 3 ss doses of the fluid extract of damiana
are substituted for the phosphorus, with advantage, or, another
excellent remedy, f3ss-j of the tincture of water pepper.
Here are three prescriptions which he frequently uses :
1. R Tc. canthar.,
Tc. nuc. vom.,
Tr. ergot aa f^j. If.
SIG. Ten to twenty drops, four times daily.
2. R Tr. sanguinarise :.. f^ss.
Fl. ex. stillingise f^ij. M.
SIG. Twenty to thirty drops, four times a day.
3. R Capsici gr. x.
Quin. sulph gr. r.
Vini xerici f jsi. M.
SIG. To be taken at bedtime.
96 Notes of Hospital Practice.
Over-Excitement of the Genital Organs. This is controlled
by gr. xx of bromide of potassium at night, and four times
a week. During the second week, the dose is increased to
gr. xxx. The use of the bromide is always preceded by a
brisk cathartic. According to Dr. Howe, the radical cure of
this class of cases consists in the patient's getting married.
TUBERCULAR MENINGITIS IN CHILDREN.
Dr. Delafield does not care to disturb the child by applying
blisters to the nape of the neck, etc. He quiets the vomiting
and increases the amount of urine secreted by the kidneys by
administering the bicarbonate of potassium and lemon juice.
In order to still further increase the secretion of urine, the
child is placed in a tub of warm water for about five minutes,
then removed, and, without drying the skin, wrapped in warm
blankets and allowed to sweat for two or three hours. When
something is required to keep the patient quiet, a mixture of
chloral hydrate and bromide of potassium is given.
MIGRAINE.
Dr. Eugene Depuy has obtained good results in some cases
by introducing brandy or strong snuff into the nostril upon
the side corresponding to that upon which the pain is felt.
Another excellent method of treatment is by throwing car-
bonic acid gas against the nasal mucous membrane in a suffi-
ciently strong jet to produce a marked impression. In still
other cases, Dr. Depuy has administered the so-called " potion
of Riverius," which consists of citric acid and simple syrup,
and bicarbonate of potassium and water, adding to it bromide
of potassium. This is an effervescing mixture, and is admin-
istered in alternate tablespoonfuls, allowing effervescence to
take place in the stomach. He recommends also occasional
mustard plasters to the nape of the neck, and the use of mild
aloetic aperients.
Nervous Diseases. 97
Dr. E. C. Seguin recommends that when a patient wakes
in the morning with a feeling as if a headache were imminent,
a drachm of paullinia powder, or the same quantity of its
equivalent, the elixir or fluid extract of guarana, be taken,
the dose to be repeated in the course of an hour, unless re-
lieved. When the pain is severe, he does not hesitate to use
a hypodermic of ^JIQQ of a grain of atropia, combined with
from 5 to 15 minims of Magendie's solution.
In the intervals between the attacks he administers a
grain of the solid extract of cannabis iudica, daily this dose
being kept up for a long time continuously.
Dr. G. M. Beard has had very good results from the ad-
ministration of caffeine, just before the attack, and of from 15
to 20 grains of the muriate of ammonia.
TEIGEMINAL NEURALGIAS.
Dr. E. C. Seguin has obtained invariably good results from
the use of Duquesnel's aconitia. His average dose is 1/100 of a
grain every four hours. He has found that the susceptibility
of individuals to this preparation varies exceedingly. Some
are over-affected by the i/200 of a grain, while others take the
*/84 w ^h impunity. He concludes that Duquesnel's aconitia
is the most powerful and the best remedy for the relief and
cure of trigeminal neuralgia.
CEREBRO-SPINAL MENINGITIS.
Dr. Thomson administers teaspoonful doses of the fluid ex-
tract of ergot and gr. v of quinia every three hours. One-
twentieth of a grain of calomel is given every half-hour.
Leeches are applied to the spine, and ice to the head and
back. If the pulse is feeble, f 3 iv of whiskey are given every
half hour.
The following is sometimes useful :
98 Notes of Hospital Practice.
A Potaaii iod gr. xl.
Ex. conii fl gtt. xl.
Aquae q. s. ad f| ij. M.
SIG. Two fluid drachms thrice daily.
HEMIPLEQIA.
If of syphilitic origin Dr. Thomson gives the iodide of po-
tassium in doses of a drachm and upwards. He also recom-
mends :
R Acid. phos. dil
Syrup. hypophos_ ............................ q. s. ad f^ iv. M.
SIG. Two teaspoonfuls in water thrice daily.
The patient is placed as much as possible upon a vegetable
and fruit diet. Meat is forbidden, and milk, eggs and fish
allowed only in small quantities. Tea and coffee are taken
but once a day ; all alcoholics, especially malt liquors, are for-
bidden. Moderate exercise in the fresh air is advised, but
fatigue is always to be avoided. Iron is given when muscular
degeneration is feared, and corrosive sublimate prescribed in
doses of 1/30 g ranl > thrice daily for a long period of time.
CEREBRAL HEMORRHAGE.
Dr. Hamilton meets increase in the frequency of the pulse
and elevation in temperature, by local derivatives and cardiac
sedatives. He thinks it unwise to use electricity in any form,
if degeneration lias begun. If there is pain, the actual cau-
tery is applied over the nerve trunks. He has derived the
greatest benefit from wrapping the limbs carefully with cotton
batting, and covering it with oil silk. Tremor is controlled
by conium and the avoidance of general excitement. Hot
baths and soaking the limbs for 10 or 15 minutes, daily, in
water as warm as the patient can bear it, are useful.
Nervous Diseases. 99
PROGRESSIVE MUSCULAR ATROPHY.
Dr. Hamilton employs electricity, and, if the extensors are
atrophied, gives support to the hand by means of the rubber
muscle.
POLIO-MYELITIS
S
Is treated by electricity, with a minimum galvanic current,
and gradually increasing its strength, allowing the muscles to
rest for a day or so between each seance. In addition to elec-
tricity, Dr. Hamilton has employed cod-liver oil, the syrup
of the iodide of iron, and strychnia, with advantage.
SCLEROSIS OP THE SPINAL CORD.
In the early stages, Dr. A. McLane Hamilton uses ergot
with good results. Later, he relies mainly upon phosphorus
and cod-liver oil, joined with galvanization and cauterization
of the cord. For the relief of the pains, he finds that hypo-
dermic injections of atrophia, morphia, or muscarine, act most
favorably. For the same purpose he employs the galvanic
current, placing the positive pole over the painful point in
the back. Warm sulphur baths, made by simply dissolving
an ounce or so of the sulphuret of potassium in water, of a
temperature not exceeding 90 F., are useful adjuvants.
EPILEPSY.
Dr. A. McL. Hamilton insists upon a careful observance
of hygienic rules. As regards medicine, he is in the habit of
combining the bromide of sodium with equal parts of the
bromide of ammonium, and of administering 1 j of the com-
bined salts, daily, together with gr. xxx of the hydrate of
chloral. The doses are divided so that the largest is given
just before the fit is expected. In other cases, Brown-
100 Notes of Hospital Practice.
Sequard's mixture of the bromides with bicarbonate of potas-
sium and a bitter tonic, acts admirably.
Dr. Hamilton regards it as of the utmost importance to
combine cod-liver oij, cream, extract of malt, or linseed oil,
with the bromide,* in the treatment.
Where the disease has no specific cause, he resorts to the
use of the actual cautery, or applies repeated blisters to the
back of the neck. He believes curare to be indicated in
obstinate cases, and injects a standard solution of this drug,
acidulated with diluted hydrochloric acid, hypodermically,
every fifth day, in doses of of a grain, until five or six
doses are given. In the lighter forms of the disease, he
employs f3 j doses of the fluid extract of ergot, thrice daily,
alternated with gtt. v doses of tincture of belladonna, the
quantity being gradually increased.
When the case gives a specific history, he combines the
iodide of potassium, or better still, the bichloride of mercury,
with the bromides, pushing the administration of the former
drugs as far as he can with safety.
Dr. E. C. Seguin treats idiopathic epilepsy with the follow-
ing formulae:
R Potassii brom J j.
Ammon. brom % ss.
Aquae font f^ vij. M.
SlG. To be given by the teaspoonful.
R Sodii brom ^j.
Ammon. brom % 88.
Aquae font f vij.
SlG. To be given b the teaspoonful.
The quantity administered is so divided as to give the larg-
est dose in the evening. The dose is gradually increased to
the production of bromism. The dose is administered in a
tumblerful of water. The bromides are continued for at least
three years after the last attack. The acne consequent upon
the long-continued use of the bromides, is combated with
Nervous Diseases. 101
arsenic, sulphur ointments, mercurial plaster, and alkaline
lotions. To correct the debility and paresis, strychnia, mix
vomica, the oxide of zinc, and quinia, are given. Nitrate of
amyl and stimulants relieve the dizziness. The patient's diet
is regulated. Cream, cod-liver oil, iron, quinia, phosphorus,
strychnia with nitro-muriatic acid, wine, beer, and whiskey,
are taken steadily, as tonics and nutrients.
INSANITY.
The bromides are employed by Dr. Segtrin to meet such
indications as epileptiform attacks, or abnormal sexual excite-"
ment, or great nervousness not caused by delusions.
FACIAL NEURALGIA
Is treated at the Presbyterian Hospital by croton chloral
given in solution with elixir calisaya; 5 grains 3 times a day
for a week.
INSOMNIA.
Dr. E. C. Seguin prescribes chloral in some cases, and in
others some stimulant, such as beer. He does not place much
confidence upon the use of the bromides here
HAY-ASTHMA.
Dr. Seguin'uses this gargle :
R Ammon. brom., (3J to ^ij-fjj) fj vj. M.
SIG. To be used as a gargle.
The nasal passages are washed out sevral times a week
with a weak solution of the same salt, (gr. x-xxx to f 3 j.)
102 Notes of Hospital Practice.
CHOREA.
If the child is run down, Dr. Hamilton administers iron
and cod-liver oil. Strychnia is given up to the point of pro-
ducing stiffness of the sural muscles. He thinks that the
application of cold to the spine cannot be over-estimated as a
plan of treatment. He either employs the ether spray, or
applies ice-bags, allowing them to stay on about ten minutes.
The spray is directed to the upper part of the cord, over the
upper cervical vertebrae. Eserine he regards as a dangerous
remedy and one likely to produce severe gastric symptoms.
Where nothing else does good, Dr. Hamilton is accustomed to
'put his patients in a dark room and keep them quiet. The
diet is carefully regulated. Among useful hygienic measures
are the salt bath and the energetic use of the rough towel.
SPINAL ANAEMIA.
Dr. Hammond prescribes gr. I/^Q of the phosphide of zinc
with gr. | of the extract of nux vomica, in pill form, to be
taken three times a day. Lately he has pursued the practice
of giving strychnia in gradually increasing doses, until there
is some evidence of the production of its characteristic physi-
cal effects. He dissolves gr. ij of the sulphate of strychnia in
f j of water, and gives Ifl x (containing gr. l/ 2 4 of strychnia)
three times during the day. On the next day, TT^xj are given
at each dose, and on the third day Tl^xij, and so on until the
paralysis yields, or the muscles of the legs become stiff. In
this latter case, the use of the drug is stopped for a day, and
on the next day he begins again with the original dose.
ACUTE CEREBRAL MENINGITIS.
If the cephalalgia is intense, Dr. Hammond takes as much
as 12 or 16 ounces of blood from the arm. Leeches are ap-
plied behind the ears. The hair is cut off short, and ice kept
Nervous Diseases. 103
constantly applied to the scalp. As a purgative, gr. x of
calomel, and gr. ij of podophyllin, are administered. He haa
derived the greatast benefit from the bromide of potassium, in
30-gr. doses three or four times a day. The head is kept
well elevated and care is taken to keep the room in which the
patient lies, cool and well ventilated, and to exclude the light
as much as possible. As food, the chief reliance is placed
upon strong beef tea. "When the strength flags in the later
stages of the disease, alcohol is administered in appropriate,
doses.
HYOSCYAMIA AS AN HYPNOTIC AND ANTISPASMODIC.
Dr. E. C. Seguin reaches the following provisional conclu-
sions with regard to the modes of action of this drug :
1. It acts upon the pupil as a mydriatic.
2. It reduces the pulse gradually and increases arterial
tension.
3. It checks bodily heat.
4. It produces hallucinations and delirium.
5. Its use is occasionally attended by a rash.
6. In large doses, it produces sleep, and something like
paralysis or paresis, and may induce retention and dysuria.
7. Theoretically, it is indicated in mania attended by rest-
lessness, delusions and suspicions, and in insomnia and convul-
sive affections.
8. It has been of especial service in acute or subacute mania,
insomnia, and those cases characterized by mischievous delirium.
9. It induces sleep more certainly than chloral, and without
being followed by bad effects.
10. In paralysis agitans it can do what no other remedy
can do.
11. It is a diuretic of no mean power.
12. Its curative power does not seem, to be great.
13. In acute chorea its use may play an important part.
Mode of Administration and Proper Dose. It can be given
104 Notes of Hospital Practice.
in small doses, hypodernaically, with ease. The doses aw
from 1/20 to 1 grain of the amorphous, and from l/ 10 o to 1/25
of a grain for hypodermic use. Distinct effects may be ob-
tained from the ^/joo f a grain.
The following formula is given for hypodermic use:
R Hyoscyamiae (Merck's eryst.) ....... .. ............... gr. j.
Glycerinae,
Aquae ....... ^... ...-.. ............................... aa TT^ 100.
Acid. carb. purse ......................................... gtt. j. M.
Each minim contains 1/200 f a g ra ' n
Tablets containing 1/50 of a grain are convenient for use by
the mouth,
Dr. Hammond regards the alcoholics as the indications par
excellence. The quantity employed is small at first and is
administered frequently and in a highly diluted form. When
alcohol cannot be employed, the carbonate or aromatic spirits
of ammonia are given.
As a tonic he regards tins mixture as of great value :
R Strychnise sulph ^ ~. gr. j.
Ferri pyrophos.,
Quinise sulph .. aa 3J.
Acid. phos. dil.,
Syr. zingiber .... ~ aa f^ ij. M.
Ft. mist.
SiG. A teaspoonful three times a day in a little water.
The diet used must be of good quality, consisting chiefly of
milk, eggs, and meat of various kinds.
The patient is encouraged to pass a good portion of each
day in a recumbent position. Emotional disturbance and
anything above moderate mental exercise is to be sedulously
avoided.
Bromide of potassium is strongly counter-indicated.
Nervous Diseases. 10-3
SPINAL CONGESTION.
T:i cases which come on suddenly, Dr. Hammond draws
blood from the spine by cups or leeches. He thinks the verge
of the anus the best place for the application of the latter. As
a purgative he administers 3 j doses of the sulphate of mag-
nesia 2 or 3 times a day. He regards the ergot of rye as of
great value in this disorder, and gives it in f 3j doses of the
fluid extract 3 times a day. When there is paralysis of the
sphincter of the bladder, or when the pain in the back is
severe, gtt. xv doses of the tincture of belladonna 3 times a
day, and a belladonna plaster is applied to the painful region
of the spine. He has found the hot douche to be an excellent
means of drawing the blood from the deep to the superficial'
vessels of the spine. The water is allowed to fall upon the
naked back over the diseased part of the cord every day for
al>out 5 minutes. Dry cups have also been found to be valu-
able adjuncts. The constant current is applied to the spine
over the affected part of the cord, the positive pole being held
at the upper limit of the lesion and the negative pole rubbed
up and down, over all the parts below. T^ie seances should
not exceed 10 minutes in length. ^ s an application to the
paralyzed muscles the induced current is employed, being used
every day for half an hour or so at a time.
Dr. Hammond considers that phosphorus and strychnia
should never be given in cases of spinal congestion.
INDEX.
Abortion .81-82
Abscess ~.~. 64
Acne Rosacea. .21-22
Alimentation, Rectal .... 18
Amenorrhcea from Anaemia 86
Ammonia, Intravenous Injection
of 17
Anaemia, Amenorrhoea from. 86
" , Cerebral 104
" , Spinal _ 102
Anchylosis, Fibrous... 59-60
Angina Pectoris..- ,.-.....~..... 51
Ano, Fistula in ~~ 62
Anthrax 64
Aortic Lesions .....~ 51
Asthma 6
" , Hay Ml
Boracic Acid as an Anodyne-... 63
Bright's Disease, Chronic
31-32 and 47
Burns 44
0.
Cancer of Tongue, Ligation of
Sublingual Artery for Remov-
al of. i 58-59
Catarrh, Chronic Uterine ..90-91
" , Naso-Pharyngeal 29-31
Cervix Uteri, Laceration of. 79
Chancre 68-70
Cholera Infantum 39-40
Chorea 102
Colles' Fracture.... ....66-67
Oough Mixture, A Disinfectant
and Antiseptic 53
Congestion, Spinal 105
Constipation associated with
Chlorosis 49-50
Constipation dependent upon de-
ficient Secretion 48
Constipation due to Chronic In-
flammation of the Rectum 49
Constipation due to want of Per-
istaltic Action 49
Constipation following Febrile
Diseases 49
Contusions 51
Convulsions, Puerperal 85-86
Cystitis following Gonorrhcea...73-74
Cystorrhagia 74-75
D.
Diabetes Ineipidus in Children... 53
Diarrhoea, Beef Tea in 32
" , Chronic, in Adults...l5-17
" due to Errors in Diet,
36-37
" due to Inflammatory
Disorders 35
Diarrhoea due to Preternatural
Acidity 37
Diarrhoea, Dysenteric 33-34
" .Flatulent 34
" , General Hints in.. ..38-39
" , Koumyss in 34-35
" , The, of Dentition... 37-38
u ,The Reduction of
Temperature in 32-33
Diphtheria 5-6
Dysentery, Acute 14-15
V07
108
INDEX.
Dysentery, Chronic 15
" , Epidemic 15
E.
Ear, Accumulations in the 19
" , Catarrhal Inflammation of
Middle 46-47
Ear, Chronic Suppurative In-
flammation of Middle 7-9
Eczema Rubra 66
Emesis 19
Emphysema 52-53
Empyema 3-4 and 62-63
Enteritis, Subacute 15
EpididymitiB 67-68
Epilepsy 99-101
Epistaxis 53
P.
Favus 50
Femur, Fractures of. 67
Fever, Scarlet ...51-52
" , Typhoid -. 22-28
" , " in Children....40-42
Fibula, Fracture of. 67
Fistula, Perineal 68
" , Vesico-Uterine 92-93
G.
Gonorrhoea, Cystitis following..73-74
H.
Haemoptysis 14
Haemorrhoids, Internal 64-66
" , Treatment of.... 7 1-72
Headache dependent on Gout... 43
" , Dyspeptic 44-45
" of Acute Alcoholism 44
" " " Cerebral
Congestion 45-46
Headache of Passive Cerebral
Congestion 46
Headache of Cerebral Anaemia... 46
Headache of Cerebral Effusion... 44
" " " Softening, 4(J
Tumors... 46
" "Rheumatism 43
u "Syphilis 43
" , Malarial 43
" , Nervous 42
" ,Sick 42-43
" ,Ursemic 43-44
Heart, Disease of the 50-51
Hemiplegia 98
Hemorrhage, Cerebral 98
" , Post-Partnm 78
Hernia, Stangulated and Incar-
cerated .'..57-58
Hip-joint, Luxation at the 54-55
Hyoscyamia as an Hypnotic and
Antispasmodic 103-101
I.
Insanity 101
Insomnia 101
J.
Jaundice 11
L.
Laryngitis, Catarrhal 48
Leprosy, The Larynx of. 31
Leucorrhcea due to Ectropion of
the Lining Membrane of the
Womb 90
Leucorrhcea due to Fungoid
Growths on the Endome-
triura 90
Leucorrhoea due to Insufficient
Diet and Consequent Nervous
Depression 90
Leucorrhoea due to the Pressure
of a Cervical Polypus 90
Lingual Artery, Ligation of, in
Removal of Cancer of the
Tongue 58-59
Lip, Cancer of the Lower 60-61
INDEX.
109
Liver, Cirrhosis of lite _..~ 20
Locomotor Ataxia, Treatment
of the Paius of. 12-13
Lungs, Gangrene of. 13
" , Multiple Abscess of. 13
M.
Mamma, Scirrhus of the 59
Meningitis, Acute Cerebral...l02-103
" , Cerebro-Spinal 97-98
" , Tubercular, in Chil-
dren 9
Menorrhagia 77-78
Migraine -96-97
Morphia Vomiting. ..... 19
Muscular Atrophy, Progressive, 99
N.
Nsevus . 55
Nephritis, Chronic. 20
Neuralgia, Facial 101
" , Trigeminal 97
Nipples, Sore 83
O.
Opium Poisoning 19
Ophthalmia Neonatorum 17
Otorrhoea, Acute Primary 17-18
Ovariotomy 83-85
Ovaritis, Chronic 88-89
P.
Patella, Fractured 67
Pelves, Labor in Kyphotic 77
Perineum, Laceration of the 77
Peritonitis, Puerperal 91-92
" .Sporadic 11-12
Pleurisy, Acute 9
" , Subacute 6-7
Pharyngitis, Croupous 22
Phthisis, Aphthae of. 10
" , Diarrhoea of. - 10
" , Laryngeal 28-29
" , Sore Throat of 10-11
Phtliisis, The Eheumatism of.... 14
" , Vomiting in 10
Pneumonia, Acute 1-3
" ., Broncho- 20-21
, Chronic 13-14
u ,Lobular 13
Polio-Myelitis 99
Pregnancy, Abdominal 79
Pruritus Vulvae due to Vaginal
Leucorrhcea 78-79
R.
Eectum, Extirpation of for Can-
cer 59
Bectum, Fissure of the 54
" , Prolapse of the 58
" , Ketroflexion with Fis-
eures and Stricture of the 89-90
Begurgitation, Mitral and Aor-
tic 18-19
Eetroflexion with Fissures and
Stricture of Rectum 89-90
Eheumatism, Acute 19
S.
Skita, Transplantation of the 68
Silicate of Lime Splint 63
Spermatorrhoea 94-96
Spinal Cord, Sclerosis of the 99
Spine, Potts' Disease of the 55-56
Stomach, Eum 52
Strapping, Wet- 66
Stricture 56-57
Surgical Dressing 63
Synovitis, Chronic 60
T.
Tibia, Fracture of the 67
Toe-Nails, Ingrowing 61
Tracoma, Acute 28
Tympanites, Treatment of. 88
U.
Ulcer, Th Chancroidal 70-71
110
INDEX.
Ursemia 20
Urethritis, Acute, Non-Specific, 68
Urine, Acute Retention of the, 72-73
Uteri, Carcinoma 91
Uterus, Retroflexion of, with
Hypersemia 86-87
V.
Vaginal Leucorrhoea, Pruritus
Vulvse due to 78-79
Valvular Lesions 50-51
Vaginismus 76
W.
Womb, Submucous and Inter-
stitial Fibroids of. 79-81
Wrist-joint, Inflammation of the, 62
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