?£！- ... ?*}| 3~*ą------ -----~~ ----- ¿T）T^* \，*\{jºsſaeº*>~~~*ae. |׫！žijí)#~*;， «ººſº º aeº; º*:-$-））.~）;„*** ~~}{ſ',-ºr.）š-*}<…“， º，* - pºſſºſ,��{};ae^{\*7^-~~~ ¡ ¿*jº&º， Ž.// ±{n>ș`:,ſ*§），ºv,ſaeŽÁ.Š（）ķ\！\， ，fţ%ĶĪZĒ;$3'，§！?, ſºſś. *** ș- ## .-! ±! !！ * ：） {,#ſºſ., ，¿jº ſº:34Ç** ºff �. . . aerººr¿T_S-（.*）\$ $=}|£gºà” ， .] №ſs-{{№_№yº, y ¿ºģ‘; ‚Ä№， ºſſ?！!！！！！！！”…,X2，…** ¿.**）, §3º%%%;： <ł „ºž43，¿zºº?, ¿x <ł „ºſ， Ž. ŽĢA ĶĪ№ №ſºſ, Žàs ºſ „ºſº，? ŽŲ Žgºſtºſsãº:!^$$， s -$2;¿?§§%ŠŤŹŹ。ſkºș*šķĶ£Wſzy§§§§šķ%.·。}}ķ%Yș-aeºf$\,%5：3 ）r.-?）. /ſ）^*\{ }=$€lºſyjº s ºſ:：：:-ïº<ſ$2，$.Ź{\,\!* *** →?“）. *s.}， źĢ*¿?§§$%ſººſ�ț¢&žÂÈ™§§§§tº§§§§§§） éκ4. № №ſſº }，\， X* X（ſ） → § ș”, „. “,*№ſſº （3C][3]\} ;--Sſ Ş}, … ~£<; º ſuff N SÈ}， _?）; *（[^>{#：S $'， '<ſáſ)§ \！^__^）！ №ſº-№-3% §§§§§§§§§§§§§§§§§§§§§§§ §§§ （*）， \ſ_]*--（º.§ ff.;**\>:gº »ºsº e º（~~\;^2},{*},<>*,\!Af: +-ſſ）?（Cºſj©šź{#¡·！fºſ*ț¢çº" （）? （º.ſ.V\} ſ_׏ź;---, º-º à： 3. X-ſiſ！！！!！--* {ſ}^3 （x-pºſ:4">~žňG ģșž$\，%ſ??}ſagae » （§ €, ºſ º！！！ ???<șºaº， №-ſÃſ*， \,\！}^{ſ}^3 “SİYº: ¿£{<}Ķºš。† 2.Ģģ{<}Ķº、。§§§§§§§§。&&&&&&&&##yſ ĶT ，~~#~';* ***.<~~ .. ！?） -;/^\s*^ ：----º ț¢·f.3-z-ø, ſvi•«.~**-<- **» （2，7 %Ģ§%}§§Çř№ ºÁ！¿?§%#žĶ27Á№&}№g§§§）;*…！§）,\！§§§§%?!?*;· «», º ; , \ / ， … <！“† ?, ſº»$ $ | ', / / №x ſº^^?^, ſº, eº, Ķ;-&• 5 ： X （) ,^， … <！--~~~}.«* :,：1 & \， : „ .^º-, º*„Ķī£.'·»， « §§§§§§§§§§§§§§§žíffff;$3： $2;&ž§§§§ }* *»\, -��***** ?)sºoq.)*įſ..ſº-* 44/● • Aſſº*Ķgºs$$$，?...！！！!！!！ #-º#：: §2è a…św.3...?：ſøºf \,+£* ¿?)\s*<'.wffr>*ŽĢ-S$ ►�ſý\ &,# # &* ?…！！！ ¿\\ 2. : ~a*… ：（ ... *,$（'#$¿?« * *… ?, }*yºeſ, º2， T3, ſa "№ Víº （\,\！;&t^{4}\，（~ſº ſº. №, №ž3°&&.|- ſººſ}}? ¿gºſſáĢņºšž№Ģš? !§§y?,?????§§§§2±%№¿S?ſá\ſ*$' 3\\$ №ſſág），��№ſķ§§\;3. №ſſág （„ſvaeſs（ $（'#3�**\\$2，$3） {}，<;$ $ $ pº 7，3%}， \ \ {3， „Słė, º À%ºs šį ŠĶA, Z?-? №ſ 3 „SÅ%, º ſae · *„T.*?：）?（?：\2-ż× :~*， -*«ť“…??！！！§ĂºÈ{{żJ§§§）º?4&#€ŽĖºș$,tae №ºĒĢģ Ķ Ķ>>žº. Šºſ 3. **{{}}****(\\ Z,\！ | 2'zºº'^ºſ ，ºàį ș:º º， №83\; &*）?）.*_{ſ\S?)（\/.*?）（5}{3}（ſ）\ſ*（:?, ? ? -↓º sae,-|-¿?§§§§ff?¿%>)$2}¿ _， _（3*x-y-z-，ș****, } [,{}STÆT;;-&3&& （（x-2--3----><！-- ***gº º*ą,... :º）T° ***（*）$（ *ſ*…….…... Æ æſº→ſ vrº. &. ,ºśț¢№ſſºſ§șºff§%ſae?№\\§§ſă、。}§%、 ŽĢšºŤ）; {$,?\> <}.\，ŽŮſ;šķº¿º:№ sły $2， ŽŪț¢ £§*:\\ſ?，?， så ...\}，ŽŪĶšļģſr$ſºļºš ~4,2 %，ºff, #3€jº ſ ºſ siiſ §§§};}{Q（ ;#4§§%.Ģk?$3，}$）;$2$ž#ffffff;&ž№ №ſſèſſè，…） -},，� ··ł ·*«&* ¿?<Ý : “ |?};s~\, \Z， SE7% º’ſ? ¿× ŠĶišķſ žºſ šķ№ºrſ， •*· a w º• -„G-kº, º evºº.};{$$$^\**ae |--- *ſå< \ſ?,��șğgºſ& & \,??.%}Ķ<)\{ ș$}<.**? ș{}^^�șº, *2x. *<！\º§%.**,ūš4:2*Źº*LÀ\ſ?§§|×* §§§§ŽŇ]ſ?º:！,��№ș<>№š&{ſ}§§Ķſ.áŒtſ，«№¿>§§ §§§§§@₪᧧§§§§§§§§§áºğ$3? ¿È¿ ¿<}K！Å.3 și¿§�-<}„gºśſe#。%% №\șiſº，}}*>}ſå} §§§§）,¿?ȧ¶√∞' '; ·Ķī£ €Ț$§§§ř,žºſiĢ§§§…ººº… （~7” º?_„...} （）3: „№s- º， ºſſae}} }=ſ'ézºïTº§-（ ）, * { { 2！ . '！}} （}）ž2%gº_（~ $_X. （*§{:g， -ºº. №ſſ“， } §§§§ſēž№:№ż№：№ț¢âșś№ ****. . .T.， ſą¿? №sºvº.}±3;&#šaº*…-· *Kºyº3）№:§à±%�Ģºsſ,ºz%}}§§§<%±§ ¶√g¿}#{}§©®%§ &ýºv;¿ſø șº§ �ºģ.ae**,*** x）;±%ș>§§\* .e.^+ （r\}/{_X ,± &\; * ſ;*4* ģk！* §§§§§§)（\ſ*$'）;§§Ź№Ş№ț¢©3)， Słyſë}$3&ſºšºſ ģ§§ №vº,§§\,^{、。<>§%！$ºſſ᧧§_■}? ». .2ÂN·tºº?Ķ-¿。Źºj·ſº;ጊº！}， №, § § （2）.3}} \!* •«…----? - &ºſſº ;·¿?, ſèſ- *}}·！t:Á É，-¿ g&§§{{ºı§3 }}\,\ x>§§§šķ???\š №ț¢,$j;§§§º Lºrţ#$%&&x（ $!pg, :�ĀŠĶķ,ļ，§§· ģ->ā�sex}----8ð ſõ_93_9ő fő $č_{ő _ſº_0ő őI 81 || 91 9Í ŽÍ 8ſ &[ [[_0[_6_8_}_9_9_Ž 8 ő [ | ſººdſ "@QAT | }, 9 g , ý & & I J & 0& 6 & 83 ， 93 gŽ †& && && LØ 0& 6 I 8 I Å, I 9I 9J yÍ 8 L &I Į Į 0Ī 6ș|"290 18 08_6ð 8ě líč 98 9ő žő && && 1& 0ő őſ 80 !!_94_9L ŻI &L &L II 01 6_8_}_9_9_Ý 8_ő [ ſ ºſ *(S&ep 09@) quÐU(19ÚIŲ (I00 pºļ00dx9 JO 9ļēp 9q) sº Aļ3 QQ89ū9q 0.Imºg 0(ſ) : pºse02 Uſoņiemīļsuºtų įstºſ º qq qoyqAA uo 0}ep Qq} ºuţI Į8}ULOZIJOĻ Tºdd'n ºuļļ uļ puſā —"SNOILOȚIIGI º XON W NĘ){}{}（[^|[ \HO NOIJLW'±[[]CI MISCA RRIAGE — IP ARTURITION. 107 employed, inserting first one corner, and gradually stuffing in the entire kerchief. All tampoms should be well oiled before insertion, using carbolized oil. Do not leave any tampom in longer than twelve hours. When it is removed, the entire contents of the womb will probably be expelled. If not, repeat, first washing out the vagina with carbolized Water, or, what is equally as good, water with a little whiskey or alcohol in it. Eacamine care- fully all clots which come away, to see if they contain the entire ovum. - - JProfuse hamorrhage is to be treated by the tampom, cold, and the appropriate drug, or injections of hot water (110° F.). If a portion of the ovum, or placenta remain in the uterus, take measures to bring it away without delay, using a wire curette in preference to a blunt hook. Depress the uterus, with one hand placed above the pubes, and attempt its withdrawal with the finger of the other, using gentle yet persistent effort. Failing in this, use the placental forceps, or wire curette. If the mass be allowed to remain, there is danger of secondary hamorrhage, or of Septicamia. After- treatment, as after labor. TO DETERMINE SEX IN UTERO. The only method possessing any element of reliability is by the rate of the foetal heart beat, according to the follow- ing table: From 110 to 125, almost certainly male; From 125 to 130, probably male; - From 130 to 134, doubtful—chances male; From 134 to 138, doubtful—chances female; From 138 to 143, probably female; From 143 to 170, almost certainly female. PARTURITION. TAKE TO CASE OF IMABOR.— Forceps, soft-rubber cathe- ter, Ergot, Chloroform, Ammonia. For perimeorrhaphy— curved needles, silver wire or silk sutures, blunt-pointed scissors. For craniotomy— perforator, craniotomy-forceps, decapitating hook. - ExAMINATION.— Observe — condition of bladder and rec- tum, vagina, and OS and cervix uteri; condition of mem- branes; pelvic capacity; determine presentation and position; Make out presentation before membrames rupture. Do not press on membranes during a pain. - RIGID Os UTERI.-Aconite.—Os hot, dry, and sensitive; patient feverish and restless. 10S RIEY NOTES OF MEDICAL PRACTICE. Belladonna. –Spasmodic rigidity of the muscular fibers of the cervix. . - Gelsemium. – Give five to ten drops of Gels. in a cup of hot water, in divided doses. - It often acts like magic in producing dilatation, and promoting labor. --J. S. Douglas. LOCAL.—Apply Bell. cerate. Warm vaginal injections. Digital dilatation. . ToUGH MEMBRANES.—Notch the finger-mail like a saw, and rub it to and fro on the bag until it gives way; or use silver catheter, or a lead pencil. TUMEFACTION OF ANTERIOR LIP.-In interval of pains press the tumor up above the crown of the head, and keep it there during two or three pains, until it is fully retracted. CYSTOCELE.-Evacuate bladder by means of soft-rubber, or silver (male) catheter, or, failing in this, use aspirator to draw off contents. - HYMEN.—Make crucial incision, if spontaneous rupture does not occur. RIGID PERINEUM.—Apply hot formentations. Between the pains, with two fingers, make backward traction on the perineum to overcome the rigidity and cause the muscles to relax. Chloroform, - Should not be given to complete anaes- thesia. It is in the following conditions contra-indicated:— 1. Do not give it to a woman who has a tendency to flood at every confinement. 2. Do not give it, when labor is complicated with severe vomiting, or with heart or lung troubles. 3. Do not give it to complete anaesthesia, except for operations, convulsions, or spasms of cervix, and then, one person should devote his entire attention to it. 4. Stop its administration if the pulse becomes weak or the respirations irregular. - - AFTER PAINs. LEADING REMEDIES. Arnica.--Violent pains, with bruised, sore feeling, pressure on the bladder, and retention of urine; after diffi- cult labor. Gelsemium.—Numbness of extremities; uterine cramps extending upward and backward. Use drop doses of the tincture. - The medicine on which I am accustomed to rely.—Hughes. Crocus. – For severe and long-lasting after-pains. No drug that I know of equals it.—R. W. Foster. Actaea.— Rheumatic subjects; excessive irritability, and over sensitiveness. Macrotin acts very promptly. AFTER-PAINS — PLACENTA PRAEWIA. 109 Caulophyllin.—After protracted and exhausting labor. Spasmodic pains across the lower part of the abdomen, extending into the groin. Belladonna.-Severe bearing down, as if everything would protrude; pains appear and disappear. Suddenly; the least jar hurts her. Chamomilla.-Great nervous excitability; pains very distressing, rendering patient irritable and ill-natured. Coffea.— Great sensitiveness, with nervous excitability; pains driving to despair; wakefulness. Secale.— Pains long and severe. Ignatia.-Cramp-like, with sadness and sighing. GENERAL MEASURES. Hot fomentations over the abdomen, or warm vaginal injections, sometimes relieve. If due to clots retained in the uterus, make pressure on the fundus, and evacuate con- tents of the womb. * As a rule do not attempt to check after-pains for at least six hours after delivery, as they are often merely caused by efforts of the uterus to expel clots or portions of mem- brane. . DYSTOCIA. PROLAPSE OF CORD. (Frequency—1 ºn 300 or 400.) If there be no pulsation in the cord, do not interfere. Otherwise, place the patient in knee-chest position, and, if possible, reposit the cord well into the uterus with the hand, or by means of a loop of tape attached to the end of a gum catheter. Failing in this, terminate labor as quickly a possible by the forceps. - PLACENTA PRAEWIA. (Frequency—1 ºv. 500.) If there be haemorrhage due to placenta praevia, imme- diately draw off the water by means of a silver catheter passed through the placenta. Keep up a firm pressure on the fundus, so that the presenting part shall impinge on the placenta. Now tampon the vagina and wait for dilatation. o not neglect the bladder. When dilatation is complete, and the placenta is implanted centrally, oil the back of the hand, pass it between the placenta and uterine walls, and first deliver the placenta, and then deliver the child with the forceps. If the placenta is implanted laterally, work at one side, and deliver the child with forceps. BRAXTON HICK's METHOD.— Bring the patient to the edge of the bed and administer chloroform. Then turn by 110 KEY NOTES OF MEDICAL PRACTIC E. the bi-manual method. Introduce the whole hand into the vagina; pass one or two fingers into the cervix (do not wait for the cervix and Os to become sufficiently dilated to admit the whole hand); rupture the membranes and turn. If the placenta is in your way, try to rupture the membranes at its margin, but if this is not feasible, do not lose time— perforate the placeuta with your finger, get hold of a leg as soon as possible, and bring it down. The leg and breech, by this method, act as tampon to the ruptured vessels of the placenta. Do not eastract the child at once — let it come by itself, or use only gentle and rare traction. The child will generally be born in One or two hours. POST-PARTUM HAEMORRFIAGE. As soon as it is discovered that the woman is “flooding,” quickly but carefully pass the hand into the uterus, and turn out all clots, fragments of placemta, etc., clearing the uterus of all contents — grasp the fundus with the other hand (previously dipped in cold water, if this can be done without delay), and hold the uterus firmly, pressing it down Žnto one of the lºac fossae with a firm, grasping pressure. Have the nurse pour a small quantity of cold water upon the abdomen from a height of several feet. As quickly as possible follow this by passing the nozzle of a syringe into the cavity of the uterus, and inject a stream of hot water— 110° to 115° F. If the delay would be too great in provid- ing for hot-water injection, use Gold water, or pass a piece of ice into the uterus. Assoon as the haemorrhage has been sufficiently controlled, to guard against a recurrence, lower the shoulders and elevate the hips; tie bands about the extremities, as near to the body as possible (let them be Snug, but not too tight); put on a Snug binder, with a compress over the uterus; give indicated remedy—Ipec., Chin., Secale, Sab., etc., accord- ing to indications on page 122. If alarming flow persist, compress the abdominal aorta to left of spine, on a line with the umbilicus, or, as last resort, inject into the uterus a solution of pérchloride of Wrom — two ownces to one pirit of water. This, preferably by means of a fountain Syringe, should be slowly and gently injected through the uterus, previously seeing that it is clear of clots. Transfusion is often successful in restoring the Woman even when exsanguine. VERSION. PoDALIC.— Best performed before rupture of the mem- branes. OS must be dilated or dilatable. Evacuate the VIERSION — FORCEPS DELIVERY. 111 bladder and rectum. Amasthetize the patient. Bring the hips to the edge of the bed. Bare the arm, and anoint the arm and hand, eaccept the palm. Use the hand whose palmar surface corresponds to the face of the child. Work between the pains. With one hand on the abdomen, introduce the other into the vagina; pass it on between the membranes and the uterine walls; carefully search for the feet; rupture the membranes; grasp one foot and bring it down, at the same time pressing the head upward with the other hand, to aid the turning process. After the breech has become engaged, labor may be at once terminated, or left to the efforts of nature. CoMBINED METHOD.—To be employed when the os is but slightly dilated. Introduce one or two fingers of one hand into the os, with the other hand on the abdomen. Deter- mine the location of the head and breech, and, by combined action of the two hands, gradually “work” the head down- ward and the breech upward, until the head is brought to present at the os, when the membranes should be rup- tured. WHEN REQUIRED–Version is called for in placenta- praevia, prolapse of Cord, transverse presentation, presenta- tion of arm, death of mother, rupture of uterus, convul- Sions, or any state in which speedy delivery is demanded, * Mºre the forceps will not accomplish the delivery of the CIlllCl. FORCEPS DELIVERY. Parts must be dilated or dilatable. Evacuate the bow- els and bladder. Anaesthetize the patient, unless the child’s head is at the outlet, when it may not be necessary. Im- merse the blades in warm water. Have the woman lying across the bed, with her hips at the edge, the thighs sepa- rated, and held by assistants. Rupture the membranes, if still intact. Anoint the convea: surfaces of the blades with lard or oil. Take position between the separated limbs of the patient. Take the male blade into the left hand; hold it almost upright; pass two fingers of the right hand a short distance within the cervix, on the woman’s right side, between the foºtal head and uterine wall, then introduce the point of blade along the inside of the fingers, and pass it, gradually lowering the handle, until the convexity of the child's head is well grasped by the fenestrated portion of the blade; depress the handle near to the perimetim. Now take the female blade in the right hand, and, beginning with the blade upright, in similar manner, but by reversed movements, pass the blade in the right side of the vagina and Cervix, bring the handle down, and lock the two. Pro- ceed gently, and use no force. 112 IXIEY NOTES OF MEDICAL PRACTICE. TRACTION.—As a rule, make traction only during a pain. The direction, if the head is high, should be first downward; but as the head gradually descends, more and more upward, until just before the head escapes from the vulva, when traction is almost at right angles with the long axis of the woman's body. Generally, the direction in which the blades point determines the line of traction. WHEN TO USE THE FORCEPS, PRECAUTION: — If the forceps must be resorted to, it is better hot to delay; rather use them a little early in the labor than Wait too long. FIRST.—In the second stage, as soon as labor flags; pains severe, uterine contractions sufficiently powerful, yet pain after pain is endured, and the head makes no descent Or advance. SEcond.— Presentation fair, head in the Vagina, Soft parts swollen, perineum rigid, pains although severe and trying, Cease to be actively progressive. * * * * - THIRD.—In posterior, occipital positions, when rectification of the position, and normal rotation cannot be effected, FourTH.— In Cases of puerperal convulsions, dangerous hæm- orrhage, extreme exhaustion; rupture of the uterus Where the head is within reach of the forceps; i. acenta, prævia, where the head is well down, after first trying the colpeurynter or tampon, giving uterine-motor stimulants, e. g., ergot, and dilating the Os. FIFTH.–In complicated labors, with prolapsûs of the cord, or . where the arm or hand descends with the head. SIXTH.—In breach presentations, to extract the after-coming head if there should be any delay. (Recommended to be applied directly to breach, in exceptional cases.) SEVENTH.-In moderately contracted pelvis, When the head is so compressed as to require assistance. EIGHTEI.— In the case of a pendulous abdomen, where We have a pendulous uterus, so that the expulsive pains are misdirected. NINTH...-In face presentations where the difficulty lies in the lower outlet, and we fail to bring the chin forward under the symphysis pubis, - TENTEI.-In cases of impaction of the foetal head. ELEVENTH.-When the mother is in feeble health and weak, so that she cannot “bear down" during a labor-pain, has an organic disease of the heart, or is subject to attacks of violent palpitation followed by syncope, or is in the last stage of pulmonary phthisis, or has a hermia, threatening strangulation, or is asphyxiated, TWELFTH.-In protracted labor from a Want of uterine power, and in Complete inertia of the womb. THIRTEENTH,-When the labor-pains are severe, but the natural powers of the mother do not expel the Child two hours after the rupture of the membrane, and a full dilatation of the os. FourTEENTII.— Any other complications or emergencies that may suddenly set in during labor, causing a delay calculated to endanger the life of the mother or child, here the forceps may hasten the delivery and remove the danger, whenever they can be practically applied. FIFTEENTH,-Rinally, whenever the mother or child runs any danger, and this danger will cease when labor is ended, the forceps are indicated. - - - CoNTRA-INDICATIONS:—In cases of distortion of the pelvis; rigid- ity of the OS uteri; in case of a hydrocephalic foetus; in case of eXtreme exhaustion, When the mother is moribund and death is imminent (here the Caesarian section may be required); where the foetus is already dead.—T. G. ComStock. - CRANIoToMy—RETAINED PLACENTA. 113 CRANIOTOMY. Place the patient in position as for the application of the forceps. Evacuate the bladder and rectum. , Pass, the fingers of the left hand up to the foetal head, and carefully pass the perforator along its palmar surface until it reaches the head, taking care that mone of the maternal soft parts be injured. Perforate the granium; break up and evacuate its contents. Earpulsion of child may sometimes be effected by the forces of mature. If not, apply craniotomy forceps, and deliver much the same as in ordinary forceps case. TWINS, As soon as the first child is born and separated from the mother, apply a binder about the abdomen, and wait for the expulsion of the other. Do not attempt removal of the lacenta of the first child until after the birth of the second. f the two placentae remain in the vagima, twist the cords. together and deliver in the ordinary manner. But be sure to tie the placental end of the cord of the first child as: soon as it is delivered. ASPHY|XIA OF THE NEW-BORN. Clear the air-passages of mucus, etc., with finger wrapped with a handkerchief, the child being inverted. Provide for supply of fresh air. Make upward friction on lower limbs. Sprinkle the face and chest alternately with hot and cold water, or, slap the buttocks. If not very soon successful, resort to artificial respiration. Infant on its back; draw the tongue forward; carry the arms well above the head; then bring them down to the sides, with elbows flexed, and press them against the sides of the chest. Repeat about twenty-five times per minute. As soon as respiration is re- stored, apply heat to the body and extremities, and give five drops of brandy in half a teaspoonful of milk and water. RETAINED PLACENTA. If due to uterine inertia, grasp the fundus through the abdominal walls, and manipulate to excite contractions. If the placenta is adherent, pass the hand into the uterus, and gently and carefully detach. Leave no fragments. See to it that the uterus is firmly contracted afterward. Follow by antiseptic imjections. If from hour-glass contraction, insinuate the hand, in conical shape, into the ring, and 8 * - 114 KEY NOTEs of MEDICAL PRACTICE. gradually and steadily overcome the resistance of the circu- lar uterine fibers. Inhalations of Amyl mit. will aid. ADHERENT PLACENTA. Pass the hand into the uterus, and gently and carefully detach the placenta from the uterine walls, being sure that ovo fragments remain. An excellent method, also, is to inject cold Water into the placenta through the umbilical cord. METHOD.—Divide the umbilical vein transversely, secure- ly tie into it the nozzle or tube of a fountain syringe, and inject cold water slowly and carefully. This method is unfailingly successful in causing the detachment and expulsion of the adherent placenta, and does no harm to the mother. PUERPERAL ECLAMPSIA. (Frequency—1 in 500.) LEADING REMEDIES. Belladonna. – Convulsive movement of limbs and mus- cles of the face; dilated pupils; red or livid countenance; fixed or convulsive eyes; foam at the mouth; involuntary escape of urine and feces; renewal of the fits at every pain; more or less tossing between the spasms, or deep sleep, with grimaces, or starts and cries, with fearful visions. If the patient is actually in a convulsion, or the ſits are recurring rapidly, Bell, is the classical remedy.—Hughes. Gelsemium.–In those cases in which the spasms occur with a rigid os uter. DOSE. – Five drops of tincture. - Veratrum vir.— Great-arterial tension, with full, hard, bounding pulse. DOSE.-Three drops of tincture. - Hyoscyamus. – Bluish Color of face; twitching and jactitation of almost every muscle in the body — of face, eyelids, and all. Almost constant delirium. A valuable remedy when due to reflex excitability.—Hughes, Aconite. — Hot, dry skin; thirst; restlessness; cerebral congestion ; general plethora. Acts like a charm.—Guernsey. - Opium.—Sopor, with stertorous breathing; incoherent wanderings, with redness, swelling, and heat of the face. Chamomilla. — Prom mental emotion, excited by a fit of anger; great excitability. GENERAL IMEASURES. Remove all sources of irritation; empty the bladder and rectum. Place a piece of rubber, or similar substance, be- tween the teeth. If all other means fail, give Chloroform PUERPERAL MANIA. - 115 to control the paroxysms, and terminate labor as soon as possible. If the urine is albuminous, and convulsions are wraºmic, then, too, the pressure on the ureters must be re- lieved by emptying the uterus. If convulsions persist, and the cervix is unyielding, incise it. PUERPERAL MANIA. CAUSES.— Great drains upon the system from too fre- quent pregnancies, prolonged lactation, or haemorrhage. Loss of sleep. Also mental shock following delivery. Her- edity predisposes. DURATION.—Twelve weeks (sometimes less) to six months in most cases. The longer it persists after six months, the more doubtful is ultimate recovery. * - PROGNOSIS.— Generally favorable both as to life and mind. Mortality slight under proper treatment. Melan- cholia more grave than Mania. Stramonium.— Furious rage, loquacious delirium; throwing off the bedclothes; nymphomania; lascivious talk. In puerperal mania, it stands highest among remedies.—Hughes. Belladonna. – Paroxysms of rage; insomnia; marked congestion of the brain, with eyes bright and shining. Hyoscyamus. - Delirium of mild type; incessant, inco- herent talking. - - Simple mania, characterized more by agitation than excitement, due to the existence of obscure illusions and hallucinations.—Lawson. Cannabis ind.— Mental delusions of an exalted char- acter. - - Cimicifuga.- : Worthy of most confidence in puer- peral melancholia.”— Hughes. Mercurius.-Symptoms pointing to phrenitis. GENERAL MEASUREs. The cardinal principles in treatment are to give the woman rest and food. She must have sleep, and must be Kept well mourished. In order to procure sleep give Chloral hyd., thirty to forty grains. After the patient has become marcotized its effect may be maintained by rectal injections of the same medicine, the dose being increased by one- fourth. - If food and medicine be refused by the patient, they must be forcibly administered. The food must be liquid in form — milk, Soups, broths, gruels. The patient must be Securely held by assistants, a dessertspoon forced between the teeth and held in that position, when liquid food, a tablespoonful at a time, may be deposited in the mouth. If this method fail resort must be had to feeding through the nares. Attach a soft-rubber catheter (No. 8) to the 116 IX EY NOTES OF MEDICAL PRACTIC E. tube of a fountain syringe, and, the patient being held, pass the catheter (previously lubricated with Glycerine) through one nostril to the fauces and beyond into the Oesophagus. In this way a quart of milk, containing the medicine when desired, may be administered. Repeat two or three times a day. Skillful nurses should have entire charge of the patient, all family friends, and especially the husband, being rigidly excluded. Change of air and scene . Sometimes has a marked effect as convalescence approaches. LACERATION OF PERINEUM. PREVENTION.—Freely lubricate the perineum, with cos- moline, oil or lard, internally and externally. With two fin- gers in the dilated anal orifice, and the thumb on the crown of the child’s head, make pressure upward and forward, toward the pubes. RREQUENCY.—Average of six observers, 27 per cent. Of all cases; more frequent in primiparas than in multiparae. Examine for it after every labor. OPERATION. IMMEDIATE.—As soon as the placenta is delivered cleanse the vagina, and if the laceration is slight, tie the knees to- gether. If considerable, cleanse thoroughly, bring the wound together by interrupted silver-wire sutures, three or four to the inch. Enter suture about an inch from the cutaneous margin of the wound, bringing it out on the mucous mem- brane of the vagina, very near the raw surface; carry it to the other side; bring together, and twist the ends. Often the wound will heal without operation if a pad, about the size of two fingers, made of cloth, be placed up against the perineum and kept in * the knees tied together, and ordinary precaution used. - - SECONDARY. — Patient should be in good health; child weaned; time, a few days after monthly period. INSTRUMENT.--Scalpel; scissors, curved on the flat; long, rat-toothed forceps; blunt-edged perimeum meedle; surgeon’s needles, curved; silver wire; needle holder; flexible cath- eter. Patient etherized; lithotomy position; labiaº held apart by hands of two assistants; shave the hair from the part; two fingers in the rectum; draw the surface tense; begin in the angle of the fissure, next to the rectum, and freshen the surface in triangular shape by snipping with the scissors and denuding with the knife; torsion bleeding arteries; be sure that the entire area of the surfaces to be brought into ap- position is freshened. Success depends on the care with which the sutures are applied. Pass the perineum needle LACERATION OF CERVIX. 117 from the cutaneous surface, deeply through the tissues, and bring the point out on the vaginal surface, close to the edge Of the wound; charge the eye of the needle with an end of the suture, and withdraw the needle; unthread it; pass it through the fold on the opposite side; thread it with the vaginal end of the wire; withdraw the needle, carrying the suture in its track. Beginning at the angle, pass sutures at regular intervals, two or three to the inch; coapt the parts, and secure the ends of the sutures by twisting, leaving long ends, which are to be brought together and secured in a short piece of rubber tube. AFTER-TREATIMIENT. Draw the urine; put a pad between the knees, and bind them together; pass catheter three or four times daily, and keep the vagina clean by mild Carbolic injections. Draw the urine with care, and hold a piece of lint to catch any drip. Protect the parts by the free use of Calendula oint- ment, prepared with Vaseline. Regulate the diet so as to restrain the action of the bowels for five or six days. Re- move the sutures, with great care, on the seventh day, and let the knees remain bound together for a week following; after that, only at night. Patient should not assume up- . right position for two weeks. LACERATION OF CERVIX. PREVENTION.—“With adequate dilatation there can be no laceration. The indications are, to procure early, prompt, and thorough dilatation, by means of fingers and forceps. If expulsive efforts set in before cervix is sufficiently dilated, urge patient to restrain voluntary efforts; oppose rapid ex- pulsion by pressure against the presenting part, and divert its movements into the proper channel.”—R. W. Foster. TIREATIVIIBNT. INDICATED.—When it is the cause of sub-involution, neu- ralgia, or other serious ill health. Do not operate if pelvic peritomitis or cellulitis present, as indicated by tenderness in neighboring connective-tissue, on pressure with the finger. PRELIMINARIES.–Large hot-water vaginal injections, once Or twice daily, for several weeks; scarification of cervix if mucous follicles enlarged and cystic. INSTRUMENTS.–Vaginal douche; Sims' speculum; vol- Sella; double tenaculum; bistoury and scissors; dissecting forceps; short needles, straight and curved; needle holder; medium silver-wire sutures. TIME.—The week following the menstrual flow. OPERATION. Patient anaesthetized; lithotomy position; large, carbol- ized, hot-water vaginal injection should be administered 118 KEY NOTES OF MEDICAL PRACTICE. just before the operation; dilate the vagina with 'speculum; draw down the cervix with volsella or tenaculum; approx- imate the edges of the cleft, to see how much tissue must be removed; now open the cleft with double tenaculum, in the hands of an assistant; with long-handled, curved scis- sors, freshen the edges of the cleft in V shape, the broad end in the angle of the cleft, and the narrow one toward the ex- ternal os; hook up with small tenaculum the portion to be removed and keep it on the stretch while it is being Sep- arated, and if possible, remove it in a single piege from side to side; get rid of all cºcatricial tissue, particularly in the angle of the cleft, using bistowry, but looking out for the cºr- cular artery, near the vaginal junction, where tissues must be removed very superficially. If there be much bleeding during the operation, hot-water injections, from time to time, will check. Let the undenuded portions, which will form the walls of the future cervical canal, be broad, and of uniform size and shape. SUTURES.–If the tissues are soft, use a round needle; if dense, lance-pointed; sutures eight ºnches long; introduce the upper one first,-three or four for each side; pass be- neath one denuded portion, across the fissure, then beneath the other. In double laceration, pass sutures of both sides before tying any. Tie the sutures from above downward. Make accurate approximation of vaginal edges. Remove the sutures, carefully, on the seventh day, the uppermost one first. - AFTER-TREATIMIENT. Confine the patient to bed for two weeks; empty the bladder by catheter for forty-eight hours; after that, give a water injection after every act of micturition. If much discharge, warm, carbolized injection once or twice daily. PHLEGMASIA DOLENS. LEADING REMIXEDIES. Aconite.— Fever; high temperature; rapid pulse; rest- lessness; thirst. Belladonna. – Skin moist; sharp pains in leg; cerebral congestion. - Bryonia.-Sharp, shooting pains, aggravated by least motion. - - - Pulsatilla. —Thirstlessness, and in the characteristic Subject. If patient not doing well under other remedies. Hamamelis. –When symptoms depend on phlebitis extending from uterine into crural veins. GENERAL MEASURES. Leg more elevated than thigh , straight or bent, as is more comfortable to the patient, supported on cushions. PU ER PER AL FE VER. 119 Insist upon absolute rest in bed. Apply heat and moisture, by light poultices, or by flannel stupes, or Hamamélès formentations, covered with cotton wool and oil silk. After the acute stage is past, bandage with roller from toes to hip while the oedema continues. Watch for collections of pus; if found, evacuate at once. Do not use friction or rubbing at any stage, lest emboli be detached. Bring up the general health by appropriate constitutional treatment. Do not lise the leg until all disease has disappeared; this is &mporta/vá. PUERPERAL FEVER, LEADING REMEDIES. Aconite. —If there be chill, followed by high inflamma- tory fever, with hot, dry skin; quick, hard pulse; mouth and tongue dry; great thirst; vomiting; urine scanty, red, and hot; cutting, burning, lancinating pains in uterus and abdomen, which is hot to touch, and excessively sensitive to slightest pressure. I believe it to be a most valuable remedy.—Dr. W. S. Playfair. Veratrum vir.— Early stage only. Nausea and violent vomiting; empty retching; much congestion of the head; full, hard pulse. By some preferred to Acom, for the first signs of congestion, inflammation, and fever. Belladonna. – Intense congestion; painful retching and vomiting; abdomen excessively sore and painful; can- mot bear the slightest jar; violent clutching pains in abdomen, with great heat; meteorism; painful bearing down in pelvis; suppressed lochia; congestion of head, with flushed face and red eyes; throbbing headache and delirium. - When the inflammation attacks the peritoneum, Bell, most fre- quently required.—Hughes. An excellent remedy for the vomiting.—Baehr. Bryonia.- If peritoneum involved, and exudation has begun. Stitching, lancinating pains in abdomen, worse from slightest motion; lochia suppressed; digestive organs much involved, though without vomiting; fever not very violent. - Colocynthis. – Severe, cutting, colicky pains in bowels; eacessive tympanies, thin Watery diarrhoea. During par- oxysms of violent pain, complexion pallid, skin alternately cold and hot, pulse quick, distressing vomiting. - Quite well indicated when tympanites is excessive.-Hughes. An important remedy.—Baehr. Arsenicum.— Sudden sinking of strength; cold, clammy perspiration; insatiable thirst; constant vomiting; burning pain in abdomen; great anguish; extreme restless- mess; rapid prostration; symptoms of decomposition of the blood. - 120 IX EY IN OTHIS OF MEDICAL PRACTICE. Veratrum alb.-Violent vomiting and diarrhoea; Sup- pressed lochia; icy-cold extremities; Hippocratic counten- ance; cold perspiration; cold breath; threatened collapse. Deserves preference if disease sets in suddenly, with great vio- lence.—Baehr. Nux v. —When the uterus itself is inflamed — puerperal metritis. - I have been astonished at the rapidity of its action.—Hughes. GENERAL MEASURES. - Wash out the vagina and uterus twice daily with a weak solution of Kali perm. or Carbolic ac, Introduce the nozzle of the syringe well through the cervix; wash the cavity of the uterus thoroughly until the water issuing from the vagina is no longer colored. Unsafe to trust this important treatment to the nurse. Apply over the abdomen a thin poultice containing an ounce of Turpentime. If tympanites very distressing, enema of Turpentine very serviceable. Use every antiseptic precaution in management of the case. Diet.— Bits of ice in mouth to slake the thirst and allay vomiting. Important to sustain vital strength by abundant nourishment. Give hot milk, strong beef tea, meat broths, and, if prostration great, café and lait. If food distasteful, give albumin water. Give Small quantities of food at fre- quent intervals. AGALACTIA. LEADING REMIEDIES. Asafoetida.-Eocessive sensibility of vital Organism; veins of breast much distended. In high repute.— Hughes. - Belladonna. – Breasis large and heavy; headache; flushed face; cerebral congestion. May afford great aid.—Hempel. Pulsatilla.-- Often called for — promotes the secretion in many cases. China. — Debility from loss of animal fluids, particularly of blood. Calcarea carb. — Leucophlegmatic constitution; ex- tremities cold and damp; inclined to too frequent and too profuse menses. - Sometimes a single dose will effect the desired improvement.— Hughes. TJrtica urens.— Entire lack of milk after parturition. GENERAL VIEASTUTEES. Warm applications to the breast will favor secretion. A strong decoction of the castor-oil plant (Rºcinus Communis) applied hot by means of Soft cloths, has been often success- fully used. MASTITIS. 121 DIET.-The use of porter, ale, and other liquors, founded on false principles. The patient should have an abundance of nutritious, easily digestible food, such as milk, Cocoa, fresh meats, eggs, broths, and whatever harmless food the appetite may crave. Milk diet is the best. MASTITIS. LEADING REMEDIES. Bryonia. – Breasts heavy, hot, hard, and painful, but not very red; breasts gorged with milk; severe stitching pains in breast; feels sick on first sitting up. DOSE.-Sixth or twelfth dilution.—Hughes. The great medicine for mastitis. Specific for mastitis neonatorum. — Hughes. Belladonna. – Breasts swollen, hard, glossy, with red streaks running in radii; throbbing, Stitching pain, accorn- panied by headache and fever. Phytolacca.-Chill, fever, painful engorgement, and swelling; the drawing of milk impossible; the gland full of hard, painful modosities. In ordinary caked breasts it is considered to be specific.—Baue. Hepar sulph. —Threatening suppuration, or after Sup- puration has begun; the discharge is scanty, and there is still great hardness of the inflamed parts. Phosphorus. -Phlegmonous inflammation; breast swol- ien, red in spots or streaks, hard nodosities. Fºstulous º with watery, discolored, offensive, ichorous dis- Charge. Has cured fistulous conditions of breast left behind after milk abscess.-Hughes. - Apis.- Burning, stinging pains, with Oedema. Conium.—When from contusion. “Specific.”—Hughes. Silica.-Chronic fistulous openings; profuse secretion of pus. Graphites.—When there are so many old cicatrices from former abscesses, that the milk can scarcely flow. It has never failed me.—Guernsey. GENERAI, WIEASURES. As soon as hardness appears, rub with olive oil, from circumference toward the center. Support the breast with sling of broad handkerchief. Apply warm fomentations, by a basin lined with flannel Saturated with hot water and Phyt, tinct. If pus has begun to form, poultice. In open- ing abscess, make incision to correspond with radius, and at most dependent part. In old sinuses and chronic suppurat- ing surfaces, two or three times daily inject Labarraque’s Solution (Liquor Soda Chlorºmatae), one part to ten of Water, . •. The most active stimulant of chronic abscess or simus I have ever known.——Dr. Jacobus. 122 IXEY NOTES OF MEDICAL PRACTICE. Binding the inflamed breast snugly, so as to give it firm support against the chest, by broad roller passed round and round the body, will avert the formation of abscess. Re- apply the binder daily, and continue until the inflammation has subsided. - - SORE NIPPLES. Arnica. — Nipples feel sore after nursing. Silica.- Much ulceration and suppuration. Phytolacca. — Nipples sore and excoriated. Graphites.— Minute vesicles, exuding glutinous fluid. GENERAL MEASUIR.E.S. The nipples should be carefully washed after each nurs- ing, and the child’s mouth thoroughly cleansed before and after being put to the breast. When sore, Hydras, and Glycerºne, equal parts, applied, will often cure. If there are suppurating Sores, apply a lotion of Calend. tinct., a drachm to an ounce, on soft cloths. If there are deep fissures or cracks, touch the raw surfaces with scale of Arg. nºt. Lotion of Phyt, exceedingly useful; apply in cracked or excoriated nipples, or fissures of syphilitic origin. Until the nipple is entirely well, cover it with rubber shield while the child, nurses. In those who are subject to sore nipples, bathe daily with Armºca lotion. METRORRFIA GIA. LEADING REMEDIES. Ipecac.—After labor or miscarriage; continuous flow of bright-red blood; the patient is cold and pale; gasps for breath; chilliness and nausea. Very frequently used.—Guernsey. The first remedy I make use of is always ſpec.—Jah?". Sabina. —After miscarriage or parturition; plethoric subjects; haemorrhage profuse, painful; blood fluid, and mixed with clots; drawing pains from back to pubes, pre- cedes the flow. - Will help in many cases.—Baehr. Used in frequency next to Ipec.—Guernsey. - China. – Heaviness of head; ringing in ears; obscura- tion of sight; fainting; face and extremities cold and pale; drowsiness; weak pulse; twitching and jerking of muscles. After loss of much blood. - Will be found of very great service.— Guernsey. Secale.— Haemorrhage from atomy of uterus, after pro- tracted labor, or in feeble, cachectic subjects; uninterrupted, painless flow of dark, fluid blood; great prostration; faint- METRORRHAGIA — MENORRHAGIA. 123 mess; palpitation of heart; convulsive movements; cold skin. . Flooding in feeble, cachectic women.—Lilienthal. - Belladonna. – Profuse discharge of bright-red, hot, blood, with downward pressure; severe pain in the back; great vascular eaccitement ; throbbing of carotids; flushed face; red eyes; full, bounding pulse. Very frequently indicated in uterine haemorrhage, particularly in that after labor.— Guernsey. Crocus.-- Pressure and feeling of weight in pelvis, with feeling of something rolling in abdomen, and discharge of dark, strºngy, viscid, tenacious blood. Frequently called for in post-partum haemorrhage.—Guerm Séy. GENERAL MEASURES. TAMPON.—Put the patient in Sims' position; with left forefinger, or Sims' speculum, retract the posterior vaginal wall; with pledgets of cotton, or free end of roller bandage, pack the vagina posteriorly to cervix; them &nteriorly; then centrally; until firmly filled by plug, taking care not to obstruct the urethra. After sufficient time has elapsed, remove piecemeal, the patient in same position. Or, take a large sponge, moisten it, and then Squeeze all the water out; compress it into small bulk, and pass it into the vagina, through a speculum. MIENORREHAGIA. LEADING REMIEDIES. Crocus.-Discharge black, viscid, stringy, and tena- cious; earthy-yellow face; debility and palpitation. Invaluable in functional form.—Hughes. Sabina.— Plethoric subjects; uterime hyperamia; draw- ing pain from back to pubes; blood bright-red. Will cure large number of cases.—Matheson. Ipecac.—Very profuse; constant nausea. Secale.—Blood dark; without pain; increased by slight- est motion. Often proves curative.-Hughes. Hamarmelis.- Profuse, dark, thin blood. Chamornilla.- Black, clotted discharge, with severe pains in the back; excessive sensibility, local and general. Has undoubted control.—Hughes. - Nux v.–Menses too early and too profuse; stops for a day or two, and then returns; irritability; sedentary habits. Trillium.— Menses every fourteen days, lasting seven or eight days; in interval, profuse, yellowish leucorrhoea; blood at first bright-red, but later is pale. For active flow we possess no better remedy.—Hale. 124 KEY NOTES OF MEDICAL PRACTICE. Calcarea carb. — Menses too early, and too profuse and long-lasting; anaemic condition; mal-nutrition; congestion of head. - Sulph, and Calc. carb., successfully administered during interval bººperiods required in majority of cases to insure a radical cure. GENERAL MEASURES. Hot water bag to lower dorsal and lumbar regions. DYSMENORRPHOEA. LEADING REWIEDIES. Actaea.—Severe pains in back, down thighs, and through the hips; hysteric spasms, cramps, and tenderness of hypo- gastrium; between menses, debility, neuralgic pains, ten- dency to prolapsus; rheumatic, irritable uterus. Caulophyllum.–Spasmodic dysmemorrhoea; bearing- down pains; scanty flow; sympathetic spasms of adjacent organs, as bladder, rectum, bowels; hysterical spasms of chest and larynx. I have had great success with Macroën and Caul., 2x trituration. Viburnum.—Spasmodic dysmemorrhoea; excruciating, colicky pains in lower part of the abdomen, coming on Sud- denly, preceding menstrual flow, lasting for hours; should be given for a week previous to the flow, in timeture or 1x. Cocculus. – Sharp, Cramp-like pains, with Scanty menses; distention of abdomen. Crocus. – Dysmemorrhoea due to spasm of cervix; men- strual blood thick and dark. - Chamomilla.-Pressure in uterus resembling labor- pains; discharge dark and clotted, with tearing pains; fre- quent desire to urinate; uterine neuralgia; excessive irrita- bility and impatience. Pulsatilla. — Menses delayed and Scanty; pains so vio- lent she tosses about with cries and tears; blood dark and clotted; flows at intervals; great chilliness; uterine con. gestion. Belladonna. — Menses too early and too profuse; blood bright-red; great downward pressure in genitals; face red and bloated; cerebral congestion. Congestive dysmemor- Thoea. SPECIAL REMEDIES. Hamamelis.- Of ovarian origin. Borax — Dysmemorrhoea with sterility. Collinsonia. — Much pelvic congestion. Coffea.—Excessive nervous excitability. Sepia.-Chronic, with leucorrhoea and debility. Gelsemium.–Spasmodic, to palliate during attack. AMIEN OR.R.H. GEA. . 125 GENERAL MEASURES. Hot fomentations across the hypogastrium, or hot sitz- bath at time of the attack if free flow. If flow is scanty, spinal ice-bag to lumbar and sacral regions; warm drinks; in the spasmodic form, Gels. at the time of the attack gives great relief. DOSE.- Three to ten drops first-decimal, fre- quently repeated. AMENORRHCEA. ILEADING REMIEDIES. Pulsatilla. —Delayed, suppressed, or scanty menstrua- tion; pains in abdomen or loins; hysterical symptoms; nausea and vomiting; palpitation of the neart; loss of appe- tite; deranged digestion; pale face; lassitude; chilliness, and headache. For the great majority of cases.—Hughes. Actaea.— Pain in left breast and side; rheumatic ten- dency; headache; nervous excitement ; peewishness; when from uterine derangement. Hysterical subjects. Sepia. — Delayed menses. Sallow complexion; fair, Sem- sitive skin; feeble, delicate subjects; leucorrhoea; ha-mor- roids and evidence of portal and pelvic congestion. Conium.— General torpor of the organs. The breasts become enlarged and painful at every period. Complicated with ovarian or uterine disease, or chlorosis. Aconite.—Sudden suppression from cold; congestion of head or chest; young, plethoric girls. Bryonia.- Bleeding from the nose in place of men- strual discharge; dry, shaking cough ; oppression of chest; heaviness or pressure in head. Phosphorus. – Delicate constitution; weak, sensitive lungs; cough; expectoration of blood, and pain in the chest. x •. Calcarea carb.-Scrofulous subjects, and those in- Clined to incipient tuberculosis; cold, damp feet. Ferrum.— Delay of first menses; debility; languor; palpitation; indigestion; leucorrhoea; sickly complexion; puffiness of face or ankles. Calc. and Fé?”. are the chief remedies.—R. N. Foster. Nux v.–– Patient of dark complexion, vehement dispo- sition, Sedentary habits; acute indigestion ; constipation. Graphites.— Menses delayed, Scânty, and painful; con- stipation ; tendency to eczematous cutaneous eruptions. Next to Puls, in frequency of usefulness.-Hughes. h Sulphur.—Scrofulous eruptions; temporary flushes of eat, - 126 KEY NOTES OF MEDICAL PRACTICE. GENERAL MEASUIRES. Keep the feet warm, and the abdomen covered with flan- nel. Warm foot baths are useful, or, the cold sitz bath. Sit in a bath, with water at 58° or 60° F., five to ten minutes, at bedtime, keeping the legs and feet Warm, and the shoulders well covered. After the bath, the patient should be well rubbed, and retire to bed. This is to be used only ºn the functional variety. When due to constitu- tonal derangement, apply the Special remedy, and prescribe mourishing diet, out-door exercise, and every means to restore the general health. In atomy of uterus electrºcity, with Conºwm. LEUCORRPHOEA. LEADING IRIENIEDIES. Alumina. – Profuse, yellow, acrid, corroding discharge, with burning in genital organs, the parts being corroded and inflamed ; worse before and after the menses; constipa- tion; inactivity of the rectum. - - Amrmonium carb.-Watery, burning discharge from the uterus; profuse, acrid, milky leucorrhoea; menses every fortnight, black, coagulated, and profuse; weak, delicate subjects. - - Calcarea carb.-Profuse, milk-like, or yellowish dis- charge, with Soreness and swelling of the vulva; too early and too profuse menses; scrofulous subjects, very sensitive to cold, with constant cold, damp feet. Pulsatilla.--Discharge thick, like cream; or, milky, Sometimes giving rise to a burning sensation; indigestion ; chilliness; nausea and trembling. Especially for those of relaxed fiber and lymphatic temperament, in whom the menses are irregular, delayed, and scanty. Vaginal leucorrhoea, in chlorotic subjects —Hempel. Specific for morbid activity of cervical glands.-Hughes. Sepia.-Pressure and bearing down in pelvis; stinging pain in ovarian region; discharge variable—thick, creamy, yellowish, bland or excoriating, offensive. Leucorrhoea at puberty, during pregnancy, or at climacteric. Debility and passive uterime congestion, in those who have borne many children.—Hughes. Helonias.-Uterine leucorrhoea, from atomy or conges- tion ; general debility from over-lactation, or other drain on the system. * Hydrastis.-Yellow discharge of an extremely tenacious character, often offensive, frequently with long shreds in it. Often accompanied by derangement of the liver and stomach. - PRURITUS V ULV-AB — OVAIRITIS. 127 G-ENERAL IMEASTUTEES. Attention to the state of the general health, of which this is usually but a local expression, is necessary. Irriga- tion of the vagina with cold water is beneficial. Calend. water or Hydras. water are better than astringent solutions as injections. PRURITUs VULVAE. IREMEDIES. Arsenicum, Sulphur, Mercurius, Rhus ven., Chryso- phanic ac. GENERAL INIEASURES. Apply compress wet with Borate Soda, two ounces; Sal- £cylic ac., one ounce; water, one quart. Also, dilute Chryso- phanic ac., locally. Grain doses of Chloral hyd. are often very effective. Carbolic ac, lotion locally often relieves. OVARITIS. LEADING REMEDIES. Apis.- Inflammation of right ovary; numbness in right side, extending down the thighs; sharp, lancinating, Stöng- Žng pains in ovary. This is one of our most reliable reme- dies in ovarian affections. Pulsatilla. — Sub-acute ovaritis, with menstrual sup- pression, nausea, chilliness, pressure on bladder and rec- tum ; pains so violent she tosses about in all directions, with Gries and tears. I believe it to be far superior to most of the remedies ordinarily recommended.—Hughes. Belladonna. – Hard swelling of ovary, with stitching, throbbing pains; constant bearing down in pelvis; perspi- ration; glistening eyes; cerebral congestion. Tachesis.-Inflammation of left ovary, with swelling tensive, pressing pains and stitches; cannot bear slightest pressure on Ovarian region. Harmamelis.-An excellent remedy in more intense form, when the peritoneal covering is not involved. - SPECIAL REVIEDIES, Aconite.— Much fever. Mercurius sol.—Threatened abscess. Hepar sulph. —To check suppuration. Thuja. – Chronic of left side; much pain. Conium.— Chronic ovaritis, with induration. I28 REY NOTES OF MEDICAL I? RACTICE. GENERAL VIEASURES. Hot fomentations, containing Hamam..., Over affected part. Rest. CLIMACTERIC. ItalEADING REMEDIES. Actaea.—Pain in left side; pain at vertex and irrita- bility of disposition ; faintness at epigastrºwm. It rarely fails to relieve.—Hughes. Lachesis.-Hot “flushes,” burning in the vertex, and faintness. Of great service.—Bayes. Gelsermium.—Flushes of heat; burning pain in top of head. Glorioine. — Rush of blood to the head; great giddi- ness; throbbing, beating, roaring in the ears. A most efficient remedy.—Hughes. Platina. –Vertigo; palpitation; headache; roaring in the ears. For those in whom menstruation has been pro- fuse and prolonged. Amyl nit.—Flushes of heat. Give by inhalation. GENERAL MEASTUIRES. Frequent warm baths are helpful in tiding the patient over this critical period. FRACTURES. 129 FART IIT. SURGERY. FRACTURES. GENERAT, CONSIDERATIONS. PROGNOSIS.–Simple fractures, if properly treated, usually recover without deformity. Eacception : fracture of the clavicle. Compound fractures may be complicated by serious. injury and suppuration or gangrene of the Soft parts, erysip- elas, and septic fever. Prognosis grave in bad cases;. guarded in the majority. TJrtunited fracture, or delayed union, liable to occur in (1) intra-capsular fractures of femur and humerus; (2) frac- tures of olecranon and patella; (3) fractures of the tibia in debilitated subjects. Fibrous union occurs occasionally in cases of delayed TIIllOIl. SIMPLE FRACTURES. - GENERAL RUILES FOR TREATMENT. 1. Reduction, or setting. 2. Immobilization until union is established. Setting must be carefully and properly done. Immobilization accomplished by means of fixed and removable dressings. Fixed dressings are made of plaster of Paris, starch, and the like. Removable dressings are fracture boxes and splints. PLASTER, OF PARIS BANDAGE. To apply a plaster of Paris bandage: (1) Wrap the limb in sheet cotton; (2) bandage it evenly with a common roller bandage; (3) prepare three to six gauze or cheese-cloth bandages, two or three inches wide, and five yards long; in the meshes sprinkle thickly dry plaster of Paris, and re-roll them; (4) place them in a dish, 9 130 REY NOTES OF MEDICAI, PRACTICE. cover with hot water, and leave them in it until the plaster is well wet; it is then ready to apply; (5) prepare a strip of tim or heavy card-board, one inch wide, and as long as the splint is to be; place this on the anterior surface of the limb —its use is to serve as a protection to the limb when cutting off the splint; (6) apply plaster of Paris rollers as an ordi- mary roller bandage; (7) have a small quantity of plaster of Paris moistened in a dish, and frequently rub some over the bandage as it is being applied; (8) when all is dome, hold the limb in proper position until the plaster sets, i.e., five or ten minutes. Cautions.— Do not make the plaster too thin; apply quickly and evenly; do not bandage too tightly; protect by Cottom upper and lower edges from touching the skin. In removing, cut on the strip of tin or card-board, with a heavy-bladed knife, a pair of Henry's Plaster Cutters, or, better still, an old steel case-knife filed like a coarse saw. * STARCH BANDAGE. To apply a Starch Bandage: (1) Apply sheet cotton; (2) bandage with ordinary roller; (3) prepare some starch; (4) apply other roller bandages, and, during the process, rub on plenty of starch; (5) keep the limb in proper position until firm. . . FRACTURE BOX. The fracture box is used in treating injuries of the leg. It consists of a solid bottom six inches wide and two feet long; two hinged sides, six inches wide and two feet long, which hook on to a foot-rest eight inches long and four inches wide, put at right angles with the bottom. The box is carefully padded with cottom or oakum, to receive the injured limb, Used in treatment of compound or commimuted frac- tures, or simple fractures with much effusion. SPLINTS, Splints may be improvised of strips of wood, 3% to 94 inch thick, or of heavy manilla board, or sole leather, etc. In order to mold manilla board or leather to the limb, immerse it in boiling water until pliable, then mold to the limb, pad with Cotton, and retain in position by means of a bandage. Caution.—Always pad splints well; especially protect any bony prominences from pressure, and thus avoid Sloughing of the skin. COMPOUND FRACTUIR.E.S. 131 Extension must be applied in some cases to keep the fragments from over-riding. Generally necessary in frac- tures of the femur and humerus—occasionally in fractures of the tibia and fibula. If the patient is seen immediately after the accident, before swelling has occurred around the fracture, a fixed dressing may be applied. If so, watch carefully, daily, for the following indications for removing the Same: (1) great pain (probably due to displaced fragments); (2) obstructed circulation (examine the fingers and toes for coldness, cyanosis, and swelling); (3) looseness of dressing. If there be effusion about the fracture, rest the limb tem- porarily in fracture box or army splint, and apply hot formentations until the swelling disappears, them dress perma- nently. A.R.MY SPLINT. A temporary splint may be made of a blanket which is folded lengthwise to a width sufficient to act as a splint in sº any given case (usually frac- tures of the leg). Roll from both ends; put the limb between the rolls, and tie a bandage around them in three places. In cases of fractures near joints, remove the dressings daily as soon as expedient (from fourteen to twenty-one days after injury), and practice passive motion for five or ten minutes, to prevent troublesome anchylosis. === COMPOUND FRACTURES. GENERAL RULES FOR TREATMENT. The question of amputation may require the best judg- ment of the experienced surgeon. POINTS IN FAVOR, OF THE OPERATION. 1. Crushing or tearing injury, rather than a fall, blow, etc. 2. Rupture of main artery, and conditions of collateral circulation. 3. Amount of haemorrhage. 4. Condition of patient, whether the system would be able to stand the long drain of healing. 5. Shock, reaction, etc. Treat the external wound antiseptically; remove all for- eign matter, dirt, gravel, splinters, etc.; remove all detached pieces of bone in comminuted compound fractures; remove all soft tissues that are very badly crushed; Wash with anti- septic solution (Corrosive Sublimate, 1:1,000; Carbolic acid, five per cent.); provide for free drainage; place the limb in a fracture box, or in a fenestrated fixed dressing. 132 IKEY NOTES OF MEDICAL PRACTICE. TJNUNITED FRACTURES. RULES FOR TREATMENT. 1. Rub the fractured ends against one another for two or three minutes, to irritate, and cause inflammation. 2. Wire the fragments together by drilling holes. Use silver wire. 3. Build up patient's general health. Separation of articular cartilages is treated on the same principle as fractures occurring near the point involved. SPECIAL FRACTURES. FRACTURE OF THE SIXUILL. PROGNOSIS.–Depends upon the brain’s injury (con- cussion, compression, or laceration) rather than the fracture. Compression and laceration are grave complications, and often fatal. Compound or depressed fractures, or fractures of the base, are much more serious than simple fractures of the Vertex. TREATMENT. In simple fractures without depression, keep the patient perfectly quiet in bed. In compound fractures, try to establish quick union of the external wound; dress it anti- septically; keep the patient in bed. In depressed fractures the fragment should be elevated if there are symptoms of compression, or irritation of the brain. Trephine, if neces- Sary to raise it. - TREPETINING. Instruments Necessary. — Scalpel, forceps, artery for- ceps, trephine, bone elevator, quill or straw, sponges, anti- Septic dressing, needles and silk, carbolized catgut. Shave the hair from around the seat of operation; wash with antiseptic wash. If the bone is not exposed, make a U-shaped incision through the soft parts over the injury, and reflect them back so as to expose the fracture. It may be possible to elevate the depressed fragments without using the trephine, if a small splinter can be removed, and thus make an entrance for the elevator underneath the depressed piece; otherwise, apply the trephine on the Sound portion of the skull, the edge touching the line of fracture. Saw evenly. After starting, withdraw the center-pin, and again Saw. After passing the diploë, go very slowly, in order not to wound the dura mater. Probe the groove frequently with a quill or straw. As soon as the dura mater is felt at One point, tilt the trephine toward the opposite side, and proceed very gently until the circular piece is entirely de- tached; then remove with the elevator. The depressed TREPHINING—FRACTURE OF NASAL BONES. 133 fragment can then be raised by inserting the elevator, and using the sound part of the skull as a fulcrum. Cautions.—Avoid trephining over any sinus or large vessel. Avoid wounding membranes. - In dressing, provide for free drainage by inserting a small tube across the base of the U. Sew up edges; dress antisep- tically, and bandage with handkerchief or Capelline. HANDRERCEIIEF BANDAGE. Use a piece of cloth, one yard Square; fold diagonally; put the diagonal on the forehead; pass the two ends be- hind the occiput, and around to the forehead again; fasten; fold the point hanging at the back up over the vertex, and fastem. CAPELLINE.— Roller, two inches wide, and six yards long. Begin at the forehead; pass backward and forward - until the vertex is closed in ; then encircle the head hori- ºny a few times, and fasten by pins at Occiput and fore- head. Fractures of the base of the skull are treated by absolute reSt. FRACTURE OF THE NASAL BONES PROGNOSIS.— Results not always favorable; may be 'some deformity; obstinate injury to treat. TREATMENT. Replace fragments by inserting a female catheter in the nares, and manipulating. Plug the nostrils with cotton for two or three days in cases of marked deformity. FRACTURE OF THE FACIAL BONES. They are rare, and very difficult to treat. No rules can be given. Surgeon must rely on his good judgment and knowledge of anatomy in each case. FRACTURES OF THE INFERIOR MAXITIL.A. PROGNOSIS.—Union in two to four weeks in simple fractures, usually without deformity. Commimuted frac- tures apt to result in deformity. TREATIMIENT. In simple fractures of the horizontal portion, use a four-tail bandage. Remove any tooth that interferes with coaptation. The upper jaw answers for a splint. Feed the patient on liquids, milk, broths, etc., by means of a rubber tube, or bent glass tube, passed between the cheek and teeth, to the space behind the molars, or through an opening made by an extracted tooth. * 134 K.EY NOTES OF MEDICAL PRACTICE. SIMPLE FRACTURE. - IDRIESSINGr. - (1) Make a four-tail bandage of a piece of cloth, one yard long and four inches wide; (2) mold a piece of (a) leather, - , or (b) cardboard to the chin, or (c) make a straight piece of wood, four inches long and one and one-half inches wide, for chin to rest on; (3) pad splint with cotton, and hold in position; (4) apply four- tail bandage to the chin, the lower tails passing over the vertex, the upper passing back of the occiput, and joining at the forehead; (5) fasten by pins where the strips cross, and hold them in position by a piece of ad to Occiput longitudinally COMMINUTED FRACTURE. TREATMENT. These fractures are difficult to treat. It may be neces- sary to drill holes in fragment and wire them together, using silver wire. Kingley’s interdental vulcanite splint is suc- cessful in some cases, but a dentist is required to make it. IDIRESSINGF. Process.--(1) Replace the fragments, and take a plas- ter of Paris cast of the teeth and jaw; (2) from this model a vulcanite mold is made, in which the lower jaw fits; (3) in this mold two stout wires are fastened, which run out the corners of the mouth and along the outside of the cheeks; (4) the mouth is fit- ted to the lower jaw; (5) a bandage is passed under the chin, and around the wire wings. By this means the mold is held firmly on the fracture of the jaw. The lower jaw thus dressed may then be bandaged to the up- per one; but the patient may be allowed to open the mouth for the introduction of liquid food. FRACTURE OF THE EIYOID BONE. PROGNOSIS.—Rarely fatal, but difficult to treat; parts are in such constant motion. FRACTURE OF SPINE. 135 TREATMENT. Reduce by manipulation, inserting finger of one hand in patient's mouth. Use anaesthetic if necessary. . Keep pa- tient perfectly quiet. Apply neck-collar of leather to im- mobilize the neck. Feed on liquids by means of tube, or introduce food well back in the mouth. FRACTURE OF THE SPINE. PROGNOSIS.—Very grave. Complete fractures are usually fatal, particularly when in cervical and dorsal re- gions. Some cases recover, but usually paralysis remains. Fracture of the vertebral processes not dangerous. Complications.—Concussion and compression of spine; paralysis of limbs, bowels, and bladder; bed-sores. TREATMENT. Perfect quiet in all cases. Extension and counter-exten- sion advisable in Some cases. Extension of head is accom- plished by means of a leather head-rest, such as is used in the treatment of Pott's disease, to which is attached a weight of three or four pounds, passing over the head of the bed. Extension of body accomplished by raising the head of the bed by two bricks under the legs. Mold sand-bags to the patient’s sides, to prevent his moving. GENERAL MEASURES. Pay particular attention to the bladder; if paralyzed, catheterize every four hours, and keep parts scrupulously clean to avoid cystitis and sloughing, often fatal complica- tions. FRACTURE OF THE CLAVICLE. PROGNOSIS.—Usually some deformity; impossible to keep the fragments in exact apposition, on account of op- posing action of attached muscles. Union established in two to four weeks. - TREATIVIIBNT. Keep shoulder elevated, and rotated outward and back- ward. Best results obtained by keeping patient on his back for two weeks. DIRESSING. (1) Put a small pad in the axilla; (2) raise shoulder by a sling under the elbow; (3) hold arm to the side by a bandage around the chest; (4) if one fragment tilts up, put a com- Yress of cotton on it, and draw it own by a strip of adhesive plaster two feet long and two or three inches wide, running from the anterior to the posterior part of the chest. 136 EEY NOTES OF MEDICAL PRACTICE. FRACTURE OF THE RIBS. PROGNOSIS.–Speedy union (in two to three weeks) if uncomplicated. If complicated with visceral injury (lungs, heart, liver, etc.), the danger is increased. The danger then is from shock, haemorrhage, and inflammation. TREATMENT. Keep patient in bed two weeks. Immobilize the wounded side by strips of adhesive plaster two inches wide, and long enough to reach from spine to sternum, applied so as to over- lap one another. Put a broad cloth bandage tightly around the chest, and hold in place with shoulder straps. Remove the dressing in one month. Apply the adhesive strips dur- ing the act of expiration. FRACTURE OF THE STERNUM. PROGNOSIS.— Usually favorable if uncomplicated. TREATMENT. If fragments overlap they can be set during a deep inspiration; dress as for fractured ribs – adhesive strips across the front of chest, and broad cloth bandage. FRACTURE OF THE SCAPULA. PROGNOSIS.— May be some deformity. TREATIVIENT. Raise the arm by a sling; put a pad over the scapula and in the axilla; bandage the arm and chest. FRACTURES OF THE HUMERUS. I. FRACTURE OF THE ANATOMICAL NECR. PRO GNO SIS.— Bony Ul IllOIl. TREATMENT. (1) Pad in the axilla; (2) molded leather or manilla board splint to the shoulder; (3) bandage the arm evenly; (4) support the hand and fore- arm in a sling. II. F.R.A.CTURE THROUGH TFIE SURGICAL NECR. PROGNOSIS.–Usually favorable; occasionally fibrous union, or atrophy of the bone. FRACTURES OF THE HUMER.U.S. 13? - TREATMENT. (1) Pad in the axilla; (2) carry the elbow forward and inward; (3) splint to the outer side of the arm; (4) bandage; (5) Sling. . III. FRACTURE OF THE SHAFT. PROGNOSIS.— Delayed union occasionally; non-union not uncommon. In oblique fractures union with shorten- ing may result. * - TREATIVIENT. - (1) Long outside splint; (2) short inside splint; (3) band- age and sling. May be necessary to attach a weight to the elbow if the fragments over-ride and cause shortening. IV. FRACTURE NEAR, THE LOWER, END. PROGNOSIS.—The nearer the elbow the more un- favorable. Danger of anchylosis of the joint from disuse. TREATMENT. (1) Dress on a right-angled padded elbow splint; (2) bandage; (3) sling. At the end of ten days or two weeks, take off the bandage and practice gentle motion of the elbow; if the fragments are united, repeat this every day to prevent anchylosis. FRACTURES OF TEIE ULNA. I. FRACTURE OF THE OLECRANON PROCESS. PROGNOSIS.—Ligamentous union not unusual. - TREATIMIENT. Dress the arm in extension by long posterior splint. In third week attempt passive motion of the elbow joint. II. FRACTURE OF THE CORACOID PROCESS. PROGNOSIS.–Favorable. TREATNIENT. Dress at right angles on an angular elbow splint. Fractures of the shaft of the ulna or radius are treated on the same plan as fractures of both bones of the forearm. FRACTURE OF BOTH BONES OF TEIE FOREARM. PROGNOSIS.— Usually favorable. May be some deformity, and may be some interference with pronation and Supination of the hand. TREATIVIENT. - (1) Dress the arm held between pronation and supination with an anterior and a posterior broad, flat, well padded 138 KEY NOTES OF MEDICAL PRACTICE. wooden splint; (2) use interosseous graduated compress, if the bones are crowded together; (3) keep elbow at right angles, and suspend hand and arm in a sling; (4) immobi- lize the wrist, but leave the fingers free. . . FRACTURES OF LOWER END OF THE RADIUS. (COLLES AND BARTON'S FRACTURES.) PROGNOSIS.— Some deformity apt to remain, par- ticularly displacement of the ulna outward, and tilting back- ward of the lower fragment. - TREATIMENT. Simplest and most efficient method of dressing is to use two straight padded splints; the dorsal, three inches wide, extending from the elbow to the metacarpus, padded heavily over the lower fragment to force it forward; the anterior, three inches wide, extending from the elbow to the wrist, padded heavily over the upper fragment. Use passive motion of the fingers and wrist in two weeks, to prevent anchylosis. ERACTURE OF THE METACARPAL BONES. TREATMENT. Use thickly padded palmar splint. FRACTURE OF THE PHALANGES. TREATIVIENT. • Dress on narrow finger-splint applied on the dorsal o palmar surface. FRACTURE OF TEIE PELVIC BONES. PROGNOSIS.— Grave. Apt to be complicated with rupture of the bladder, urethra, or rectum. s T.R.E.A.TIMIENT. Rest in bed. Fragments may sometimes be replaced by manipulation in the rectum. If bladder or urethra is injured, pass a catheter, and retain it if necessary. Perineal section demanded in some cases of extravasation of urine. FRACTURES OF THE FEMUR. I. INTRA-CAPSULAR FRACTURE OF THE NECK. PROGNOSIS.–Unfavorable. Rarely bony, usually ligamentous, union; sometimes non-union. FRACTUREs of THE FEMUR. 139 - TREATMENT. Quiet rest in bed for three or four weeks; (eather hip- splint; good diet; keep the patient's strength up. At the end of four weeks, let the patient up on crutches. - II. EXTRA-CAPSULAR FRACTURE OF THE NECK. PROGNOSIS.— Better than in intracapsular; union, bony; but there is apt to be some lameness; union in six or eight weeks. - - TREATMENT. If not impacted, the treatment is the same as for fractures of the upper and middle parts of the shaft. Let patient get up on crutches in four weeks. III. FRACTURES OF THE UPPER, AND MIDI}LE THIRDS OF THE SHAFT. . - PROGNOSIS.— Deformity not uncommon from over- riding and displacement of the fragments. Union in from six weeks to two months. . TREATMENT. 1. Extension.—Apply two E--HH- Swansdown plaster strips, three –=t inches wide, one on each side of UEl the leg, from the knee down to a ETX-tº- few inches above the ankle; to g the free ends of the straps, which º should reach eight or ten inches below the sole of the foot, fasten ` a bit of wood, four inches by two, and attach a cord and weight to this. 2. Bandage from the toes up to the groin, holding four padded wooden splints running sº on the four surfaces of the <2% thigh over the fracture. 3. Apply Liston's long side-splint. 4. Put the patient on a hard bed. 5. Raise the lower end by means of bricks. 6. Mold sand-bags or cushions to the sides of the leg. . Use a weight -S º of from eight to six- teen lbs., according t to the age of the ºzº - º Light ÉE::=3% weights in commin- +======TETº uted fractures. 2=ººls º Allow patient to get up and exercise on crutches in four weeks, if everything is favorable, having a long side-splint or a starch bandage on for protection. 140 KEY NOTES of MEDICAL PRACTICE. IV. FRACTURE OF THE LOWER THIRD. PROGNoSIS.–Favorable, unless the knee joint is involved. . - TREATMENT. Dress on a double inclined plane. Fractures of the shaft of the femur may be treated by plaster of Paris fixed dressing, which is applied while the limb is held in extension. FRACTURE OF THE PATELLA. PROGNOSIS.— Guarded. Fibrous union not uncom- mon. Anchylosis probable, unless passive motion is used. TREATMENT. Dress limb with knee in extension, and thigh slightly flexed, on an inclined plane. Effusion reduced by hot fomentations, or aspiration. Draw the fragments together by two strips of plaster, one and one-half inches wide, and long enough to pass obliquely around the knee. Apply them on the figure-of-eight plan. Glſº ū Bandage firmly to prevent ef- aſſº fusion. Union in six to eight sº weeks. Practice passive mo- *tion in three or four weeks. . FRACTURES OF THE TIBIA. . . PROGNOSIS.–Usually favorable; may be delayed, or non-union. Union occurs usually in six or eight weeks. TREATMENT. Put the leg in a fracture-box for two or three weeks; then dress in plaster of Paris or heavy pasteboard splints, and let the patient get about on crutches. FRACTURES OF THE STIAFTS OF TEIE TIBIA AND FIBULA. PROGNOSIS.— May be some deformity from shorten- º Delayed union sometimes. Union in six to eight WeekS. - -- TREATMENT. If there is effusion, use a fracture box and hot formenta- tions. If shortening, apply extension below the fracture — weight about three pounds. Put on a fixed dressing in two or three weeks; plaster of Paris, or heavy board splints. In four or five weeks, allow patient to go about on crutches, ERACTURES OF FIBUL.A. 141 DELAYED OR, NON-UNION OF FRACTURED TIBIA. 1. Produce irritation by rubbing the fractured ends together. 2. If that fails, operate. . Instruments.-Scalpel, bone forceps, or Small Saw, bone drill, silver wire, needles, silk, etc. - OPERATION. - (1) Make a linear incision across the fracture; (2) snip or saw off any projecting points of bone; (3) drill holes obliquely through the edges of both fragments, and pass a wire through them; (4) draw the pieces together firmly by the wire. One or two wires are sufficient. Provide for drainage; close the edges; dress antisepti- cally, Remove the wire in two or three weeks. FRACTURE OF FIBUL.A. (POTT'S FRACTURE.) PROGNOSIS. — Favorable. Some trouble with the ankle apt to remain. TREATMENT. I)upuytren’s Method.—Padded board splint, six inches wide, and reaching from the knee to two inches below the foot; pad most heavily above inner malleolus; apply to the inner aspect of the leg; bandage the foot firmly to it by means of figure-of-eight bandage; fasten the knee firmly; do not apply the bandage over the fracture. Union in six weeks. The patient may get about on crutches in two or three weeks. - 142 KEY NOTES OF MEDICAL PRACTICE. DISL00ATIONS. GENERAL CONSIDERATIONS. SIMPLE DISLOCATIONS. PROGNOSIS.— Good in recent, simple dislocations, if properly treated. Danger of becoming again dislocated if the joint is used too freely or too soon after reduction. This may lead to habitual dislocation. If a dislocation is not reduced shortly after the accident, the displaced bone becomes more or less firmly adherent in its new position; the old articular cavity becomes filled with inflammatory products, and the result is an irreducible dislocation. Ball-and-socket joints are reducible after a longer period than any other kind. Dislocated shoulders have been reduced at the end of four months; the hip at the end of two months. - TREATMENT. Reduction.— Reduce as soon as possible after the acci- dent. Anasthesia is often required to relax the muscular contractions and deaden pain. Reduction is best accom- plished by manipulation (see special dislocations). Obstacles to Reduction.— (1) Contraction of muscles (overcome by anaesthetics); (2) very small rupture in the capsule of the joint, which is closed by the overlapping of the soft parts; overcome by manoeuvring, or by subcutane- ous incision of the capsule, if necessary. In the reduction by manipulation everything depends upon a correct anatomical knowledge. AIFTER-TIREATINTENT. (1) Subdue synovial inflammation after reduction by cold or hot compresses; (2) keep the joint at rest for about two weeks before attempting any motion. If motion is attempted too soon, there is danger of re-dis- location. HABITUAL DISILOCATIONS. PROGNOSIS.–Unfavorable for a permanent cure. Danger of becoming dislocated anew every time there is an extra strain upon the joint. . TREATIMIENT. Reduce, and immobilize the joint until it has become a little stiff, then practice gentle motion. Treatment often fails. IRREDUCIBLE DISLOCATIONS. PROGNOSIS.—Reduction is out of the question on account of adhesions, and obliteration of the original articular cavity. COMPOUND DISLOCATIONS. 143 - TREATMENT. - - An effort may be made to make a false joint at the point where the head is adherent. COMPOUND DISLOCATIONS. PROGNOSIS.— Grave. It is much more serious than a compound fracture. The danger is from suppuration, septicaemia, hæmorrhage, etc. TREATIVIENT. Resection or amputation is demanded in many compound dislocations, especially of the larger joints. If it is deemed advisable to attempt to save the limb, use a thoroughly antiseptic dressing, and dress in a convenient position if anchylosis occurs. DISLOCATION COMPLICATED WITH - FRACTURE. PROGNOSIS.— Guarded. Danger of anchylosis of the ioint. . J TREATMENT. Reduce the dislocation; dress as for an ordinary case of fracture. In ten days practice passive motion of the joint very gently. Repeat at the end of five days, and after that as often as deemed advisable. - SPECIAL DISLOCATIONS. DISLOCATION OF THE LOWER. J.A.W. PROGNOSIS.— Good. May be reduced after four months’ standing. If not reduced, the jaw will accommo- date itself to the new position, and, in time, a certain amount of motion will be acquired. TREATIMIENT. - - Reduction.— Depress the lower jaw sufficiently to free the condyle from the eminentia articularis of the temporal bone, and then push it back to its place. 1. Depress the lower jaw by inserting the thumbs behind the molar teeth and drawing downward. Protect the thumbs from injury by wrapping cloth around them. 2. A piece of wood may be used as a fulcrum, by placing it between the molars, and them prying upon the chin. When the condyle is free, push the jaw into position. DISLOCATION OF THE VERTEBRAE. PROGNOSIS.—Very grave. If recovery follows, the patient is apt to be paralyzed. TREATMENT. Any treatment other than absolute rest is extremely dangerous. Patients are apt to die during attempts at 144 KEY NOTES OF MEDICAL PRACTICE. reduction, but some recoveries have followed such endeavor. The indications are to use sufficient extension to disengage the locked parts, and then replace the displaced portion with gentle pressure. DISLOCATIONS OF THE CLAVICLE. PROGNOSIS.— Guarded so far as perfect recovery is concerned. Danger of habitual dislocation. • TREATIMIENT. Easily reduced, but difficult to retain in position. DISLOCATION OF THE ACROMIAL END. Pass a bandage from the elbow up the back, over the dis- location, down the front, under the elbow, up the back, over the shoulder, across the front of the chest, under the oppo- site shoulder, around the back, and then bind the injured member to the chest by two or three turns of the bandage. DISIOCATION OF THE STERNAL END. Keep the chest thrown forward, and the shoulders back; strap a compress over the dislocation with an adhesive plaster. DISLOCATIONS OF THE HUMERUS. PROGNOSIS.—Usually good. Occasionally reduction is difficult. VARIETIES.—Sub-glenoid; sub-coracoid; sub-clavicular: Sub-Scapular. - -------. TREATIMIENT. SUB-GLENOID DISLOCATION. Anaesthetize the patient if necessary to overcome muscu- lar contractions. While an assistant extends the arm downward parallel with the body, the surgeon pulls the head of the humerus toward the socket. If alone, the Surgeon may seat the patient in a chair, and resting one foot on the chair, place the knee in the axilla, and extend the arm over the knee. Sometimes much difficulty is experienced in setting. SUB-COR A COID DIST.OCATION. The treatment is the same as for sub-glenoid dislocation. . SUB-CLAVICULAR DISTIOCATION. Use sufficient extension to free the head of the humerus from the tendons of the biceps and coraco-brachialis, and then proceed as in the sub-glenoid dislocation. SUB-SCAPULAR DISLOCATION, This is a very rare dislocation. Treatment is simply extension outward and downward. N. B.- In all dislocations, immobilize the joint for at least two weeks. - - DISLOCATIONS OF THE ELBOW. 145 DISLOCATIONS OF THE EIBOW. PROGNOSIS.–Usually good. Forward dislocations of the radius liable to become habitual. VARIETIES.—(1) Dislocation of both bones backward, or forward; (2) lateral dislocation of both bones; (3) dislo- cation of one of the bones. TREATINIENT. DISLOCATION OF BOTH BONES BACKWARD. Place the knee in the bend of the elbow, flex the fore- arm, and make extension on the hand and Wrist. DISLoCATION OF BOTH BONES FORWARD. Rare. Forced flexion of the forearm and pressure will reduce it. DISLOCATION OF THE HEAD OF THE RADIUS. Reduction accomplished by extension of the forearm and pressure upon the head of the radius toward the Socket. Dislocations of the ulna very rare. DISLOCATION OF THE WRIST. PROGNOSIS.–Good. Simple dislocations of the wrist are rare. Usually complicated with fracture of the radius (Colles' Fracture). - - TREATMENT. Extension of the hand and pressure upon the displaced bones will reduce this dislocation. DISLOCATION OF THE FINGERS. TREATMENT. - Easily reduced by extension. Bind on a splint for a week after reduction. DISLOCATION OF THE THIUMIB, Bend the metacarpal joint into the palm of the hand. Press the first phalanx of the thumb backward. Pull the thumb downward toward the tips of the fingers, flex the thumb into the palm of the hand. - DISLOCATIONS OF THE HIP. PROGNOSIS.–Usually favorable. Sometimes diffi- cult to reduce. Safe to attempt reduction four weeks after Injury. - - VARIETIES.—(1) Dislocation on dorsum ilii; (2) disloca- tion in sciatic notch; (3) dislocation into thyroid fora- men; (4) dislocation on pubes. - - - TREATMENT. - DISLoCATION ON THE DORSUM ILII. Anaesthetic required in all dislocations of the hip, Put 10 14.6 KEY NOTES OF MEDICAL PRACTICE. the patient on his back. (1) Flex the knee and hip well; (2) adduct the thigh , (3) rotate outward; (4) suddenly bring limb down in a line straight with the body. DIS LOCATION INTO THE SCIATIC NOTCH. Method of reduction the same as for dislocation on dor- sum ilii. IDISLOCATION INTO THE THY ROID FOR AMEN. (1) Flex the hip and knee; (2) abduct; (3) rotate inward; (4) adduct; (5) straighten the leg. DISLOCATION ON THE PUBES. Same as in dislocation into thyroid foramen. DISILOCATIONS OF THE PATELLA. PROGNOSIS.–Usually favorable, unless there is com- plete rotation on the axis. - VARIETIES.–Ilateral, and on its own axis. TREATMENT. Lateral dislocations reduced by relaxing the quadriceps extensor, and manipulating the patella. (1) Put the patient on his back; (2) flex the thigh; (3) hold the knee in ex- tension; (4) press the patella into position. If rotated, try to reverse it by manipulation. It is not always possible. Ruptures of the ligamentum patellae, or of the quadri- ceps tendon, are treated by stitching the ruptured ends together with carbolized catgut or silk. Operate under antiseptic precautions, and do not open the knee joint. DISIOCATIONS OF THE TIBIA. PROGNOSIS.–Favorable in simple dislocation; usu- ally incomplete. VARIETIES — Ilateral, backward, and forward dislocations. TREATMENT. - (1) Lateral dislocations reduced by extension and pres- sure, or rotation in the proper direction; (2) backward dis- locations reduced by extreme flexion; (3) forward disloca- tions by extreme extension. Compound dislocations usually call for immediate amputation. DISLOCATION OF THE ANKLE JOINT. PROGNOSIS.–Usually favorable. May be compli- cated with fracture of fibula, i.e., Pott's fracture. . TREATMENT. - Simple dislocations easily reduced by extension and press- ure in proper direction. DISLOCATION OF THE TARSUS. PROGNOSIS.— Guarded. Difficult to reduce. TREATMENT. Attempt reduction by extension and pressure. Resection required in compound dislocations, AMP UTATIONS. 147 AMPUTATIONS. G-ENERAL CONSIDERATIONS. PROGNOSIS.—The prognosis is influenced by (1) age; (2) general health; (3) circumstances demanding amputa- tion. 1. The younger the patient, the more favorable the out- look. 2. Tubercular diathesis, broken-down constitutions from disease or dissipation, cloud the prognosis. 3. Amputations after accidents, acute joint diseases, etc., are more formidable than in chronic diseases. Death occurs from (1) shock; (2) ha-morrhage; (3) blood- poisoning, etc. . . OPERATIONS. VARIETIES.—(1) Flap; (2) circular; (3) mixed skin-flap, and circular of muscles. - 1. Flap operations made by lateral or antero-posterior flaps of the muscles and skin. 2. Circular operations made by first cutting through the skin transversely around the limb, reflecting the skin cuff, a distance equal to one-half the diameter of the limb, and then cutting through the muscles to the bone. Retract the muscles as much as possible, and saw the bone. - 3. The mixed operation consists in making skin-flaps, reflecting them back to a proper point, and then making circular cuts of the muscles. - STEPS OF ANT OPERATION. - Instruments. –Amputating knives, bone saw. bone for- ceps, artery catch-forceps, ligatures, needles and silk, an Esmarch's bandage, or tourniquet. Have plenty of assist- ants. - 1. Apply Esmarch’s bandage to the limb; use compres- sion of subclavian and femoral arteries in the shoulder or hip-joint amputations. 2. Wash the parts thoroughly with antiseptic solution. 3. Divide the soft parts by flaps, circular, or mixed method. 4. Saw the bone, removing any sharp edges with bone forceps. 5. Search for main artery and ligate. 6. Loosen the bandage cautiously; secure bleeding arte- ries and ligate. 7. Irrigate the flaps with antiseptic solution. 8. Control capillary oozing by compression, by hot water, or, if necessary, in rare cases, by solution of Sulphate of QM'07). 148 KEY NOTES OF MEDICAL PRACTICE. 9. Wash all clots off the flaps, and stitch them together, after providing for drainage by inserting a drainage tube. 10. Dress the wound antiseptically. AFTER-TREATMENT. Treat shock by stimulation, giving teaspoonful doses of brandy every half-hour. Allay pain with Morphia, one-eighth grain doses, when necessary. - Treat secondary hapmorrhage by (1) elevating stump, and using pressure; (2) by opening wound, and Securing bleed- ing vessel. Treat surgical fever by Acomºte. - Treat blood-poisoning by Baptisia; Sulphate of quºmia, One grain every two hours, and stimulation, giving a milk punch every three hours. SPECIAL AMPUTATIONS. AMPUTATION AT THE SHOULDER JOINT. Mortality.—Two out of three recover. OPERATION. & Lateral flaps. Have one assistant compress the subcla- vian, by pressing it against the clavicle; another to hold the limb; a third to be in readiness to seize arteries. 1. Make external flap to include most of the deltoid muscle. The curve of the flap should extend from the acromion process downward, outward, and backward, almost to the posterior border of the axilla. - 2. Open capsule, and free the head of the humerus of muscles attached to tuberosities. 3. Dislocate the head outward; pass the knife close to the inner side of the humerus; cut downward, and finally Hººd, through the remaining soft parts, to make the inner 18,0. º, Assistant should follow the knife closely during this procedure, and grasp the axillary artery before, or, as it is being Severed. Ligate it at once, and then the vein. Next secure and ligate the circumflex, sub-scapular, and any other arteries. Complete the operation as directed in General Consider- ałżons. - - AMPUTATION OF THE ARM. OPERATION. Use flap, or circular method. Have one assistant hold the arm. 1. Apply Esmarch's bandage. 2. Make antero-posterior flaps. - 3. Hold them back with retractor, and saw the bone. 6. Secure and ligate the brachial artery. SPECIAL AMPUTATIONS. 149 5. Loosen the bandage cautiously, and ligate other bleed- ing vessels. - . 6. Complete the operation as directed in General Consid- erations. - AMPUTATION OF THE FOREARM. Use the mixed method. 1. § Esmarch's bandage. 2. Make antero-posterior skin-flaps, the forearm being held between pronation and supination. 3. Make circular incision of the muscles. 4. Divide the interosseous membrane. 5. Protect the soft parts by a three-tailed retractor, and saw the bones. 6. Four arteries to be ligated, the radial, ulnar, anterior, and posterior interossei. - - Complete the operation as directed in General Consider- atoms. AMPUTATION OF THE FINGERS. Usually done by disarticulation. I. DIS ARTICULATION AT THE PEIALANGEAL ARTICULATIONS. Control haemorrhage by an elastic rubber tube tied around the base of the finger. 1. Strongly flex the joints of the finger, and make an incision in the crease of the knuckle, thus opening the joint. - 2. Divide the lateral ligaments. - 3. Make long flap of the muscle in front of the disartic- ulated phalanx. - Complete the operation as directed in General Considera- $ºoms. II. DISARTICULATION AT THE METACARPO-PHALANGEAL JOINT. #Pº an Esmarch bandage at the wrist. 1. Make a pear shaped incision from the knuckle around the finger. - 2. Sever the lateral ligaments of joint, and disarticulate. Complete the operation as directed in General Gomsidera- tºo?vs. , - AMPUTATION AT THE HIP JOINT. Mortality.—The most formidable major operation in surgery. About one-half the cases die. OPERATION. - Have one trusty assistant to compress the femoral artery at the brim of the pelvis; a second to hold and manipulate the limb; a third to secure the arteries. Draw the patient to the end of the table, so that the buttocks shall project. - An abdominal tourniquet may be used. 150 KEY NOTES OF MEDICAL PRACTICE. 1. While second assistant holds the leg slightly flexed, adducted, and rotated inward, the surgeon inserts the knife between the anterior Superior spine of the ilium and great trochanter. The point should pierce the capsule and emerge in front of the tuberosity of the ischium. Cut downward, close to the bone, until third assistant can put his fingers into the wound and seize the femoral vessels, then complete the anterior flap, making it from seven to ten inches long. 2. Open the joint, if it was not done before, and disar- ticulate the head of the femur; the second assistant at the same time extending the thigh and rotating outward. 3. Finish the amputation by making a short posterior flap. º %. Ligate the femoral, profunda, obturator, and sciatic arteries. - Complete the operation as directed in General Considera- tºoms. AMPUTATION AT THE THIGH. The operation resembles that of the arm. Lateral flaps are preferable at the lower third. The circular method may be used. - The arteries to be ligated are femoral, profunda, external circumflex, and anastomotica magna. AMPUTATION OF THE LEG. Mixed method very serviceable. In sawing the bones, complete the division of the fibula first, and bevel off the sharp anterior edge of the tibia. - AMPUTATION AT THE ANIKI.E. . . Syme’s Operation. — Disarticulation at the ankle joint. 1. Make incision from half an inch below the inner mal- leolus, across the dorsum of the foot to the outer malleolus. 2. From the ends of this incision make a second, running downward and slightly backward under the heel. 3. Carefully dissect the os calcis, and disarticulate at the ankle. 4. Ligate the anterior tibial, and both plantar arteries. AMPUTATION OF THE FOOT. Chopart's Operation.— Disarticulation between astra- galus and the os calcis on One side, and Scaphoid and cuboid bones on the other. • 1. Short dorsal, flap, beginning from prominence of Scaphoid to one inch behind the fifth metatarsal. 2. Disarticulate. - 3. Make long plantar flap extending to the roots of the toes. 4. Ligate the dorsalis pedis, plantar, and digital arteries. Complete as under General Considerations. SPECIAL AMPUTATIONS —TRACHEOTOMY. 151 Lisfranc's Operation.— Disarticulation between the tarsus and metatarsus. - . 1. Dorsal incision from one inch before prominence of Scaphoid to base of fifth metatarsal. 2. Disarticulate; remembering that the second metatarsal is back about half an inch. . . . . - 3. Make long plantar flap. * Complete as directed under General Considerations. AMIPUTATION OF THE TOES. Operations similar to those on the fingers. . CUT THROAT. PROGNOSIS.— Guarded. If an important vessel is injured, death is almost immediate. Death may occur pri- marily, from (1) ha-morrhage; (2) Suffocation; secondarily, from (1) blood-poisoning; (2) pneumonia. - TREATMENT. 1. Ligate the bleeding vessels. 2. When the larynx or trachea is injured, remove clots, and insert a tracheotomy tube, if necessary. 3. Provide for free drainage, and stitch the edges together. - 4. Keep the head flexed on the chest. 5. Feed vigorously. If the Oesophagus is injured, use a stomach tube. - - 6. Watch the patient, and prevent suicidal attempt. FROST BITES. Warm the frosted members gradually. Avoid hot water and fires at first. Use friction with cold flannels, furs, etc. After circulation is restored, treatment the same as for burns. - Dress with carbolized oil (Carbolic acid, 1 oz., Lönseed oil, 1 pint), and wrap in cotton. If gangrene follow, wait for line of demarcation, and amputate. . TRACHEOTOMY. Indications.— (1) foreign bodies in trachea, bronchi or pharynx; (2) scald of glottis in children; (3) prelimi- nary to extensive operations about the jaws and throat (administer anaesthetic through tracheal tube); (4) croup and laryngeal diphtheria, with laryngeal dyspnoea, indi- cated by presence of considerable exudation in larynx, and respiration so difficult that there is sinking in of the sternum and of the supra-clavicular spaces with each inspi- ration. Contra-indicated.—Auscultate posterior chest – if one lung seriously obstructed, tracheotomy is contra-indi- cated. - - 152 KEY NOTES OF MEDICAL PRACTICE. Instruments.-Scalpel, curved bistoury, tenaculum, two strabismus hooks, two or three catch-artery forceps, sponges, tube with tapes. Chloroform may be given if time permit. Local anaes- thesia by ether spray or by Cocaine. If no anaesthetic is used, wrap the child in a shawl to secure the limbs. OFERATION. - Place the patient on a firm table in front of a good light; put a small, firm pillow (quart bottle rolled up in a towel will answer) under his neck to make the trachea prominent, The operator standing on the right side of the patient seizes the trachea between the thumb and finger of the left hand and fixes it until exposed by the incision. The incis- ion should be free, extending from cricoid cartilage, from one and one-half to two or more inches downward, includ- ing integument and cellular tissue. It is to be deepened by successive cuts, or by hooking of tissues aside until the tra- chea is reached, the operator keeping strictly in the median line. - - The trachea reached, four or five rings should be cleared by blunt hooks or handle of scalpel. The operator then hooks the tenaculum into the trachea at the highest point exposed, and making traction upward (now for the first time releasing the trachea from the grasp of his left hand), with the sharp bistoury cuts from below upward a sufficient extent of trachea to admit the canula. The wound may be held open with the blunt hooks until, by suction, the tra- chea is cleared of blood, mucus, or other foreign matters. The outer tube may then be inserted, and secured by tying tapes about the neck. The inner tube, slightly moistened with glycerine, may be put in place, the opening covered with several thicknesses of gauze, to filter the air, and the patient placed in bed. The tube should be large enough to permit quiet breathing. During the operation the bleeding vessels may be seized with catch-forceps, which are allowed to fall toward the sides of the neck, making lateral traction. Free ha-mor- rhage should be checked by forcipressure, if time be lim- ited, or torsion, if not, before trachea is opened. General oozing, from congestion, is best checked by opening of trachea relieving congestion, and by pressure of canula. Should thyroid isthmus appear in track of imcision, hook upward or downward, or incise it. After operation, the inner tube must be removed often, and thoroughly cleansed, the small bristle brushes used for feeding-bottles answering well; or, a stiff feather, properly trimmed. - . If operation be made for foreign body, the trachea may be held open and the body extracted by suitable forceps; if this is not feasible, insert tube and wait. HERNIA — HERNIOTOMY. 153 HERNIA. Reduction.—Taavis.--Anaesthetize the patient; place him in Supine position with legs drawn up. Resisting forces. tightness of constricting ring, and swelling of strangulated viscus, Manipulate the hermia as nearly as possible in the line of axis of the ring — compress gently, but steadily, for a long time. While keeping up pressure with one hand, with finger and thumb of other manipulate the neck of the tumor back into the abdomen. Effort Inay be made to dilate the constriction with the finger at the internal abdominal ring. Pass the finger along the inguinal canal, carrying the integument before it until the constrict- ing ring is felt, which is generally easily done; the finger is then insinuated into the opening, and if the band of oppos- ing fibers does not readily yield, gentle pressure is made against the upper border of the ring until it is felt to give way, when a resort to gentle taxis will often be successful. When reduction occurs the bowel goes back suddenly, with a gurgle. Aspiration by No. 1 needle occasionally facili- tates reduction after failure of gentle taxis. Or, give the patient twenty minims Laudanum, place him in a warm bath for twenty minutes, then between warm blankets, and try taxis. Taxis should be gentle and thorough, and tried only once before resorting to operation.—Adams. Unskillful taxis is a more frequent cause of death than the knife. —Hamilton. - Indications for Operation.— Symptoms of intestinal obstruction with an irreducible hermial protrusion. HERNIOTOMY. Instruments.-Scalpel, forceps, director, artery for- Ceps, ligatures, retractors, hernia director, hermia knife, Sponges, and accessories. Shave the parts and empty the bladder. Patient anaes- thetized, supine, thigh slightly abducted and rotated out- Ward. . Note positions of spine of pubes, Poupart’s liga- ment, femoral artery. Make incision free enough to give access to stricture. Divide the coverings of the sac layer by layer, on director. Tie and cut superficial epigastric artery, if exposed. When sac is exposed reduce the hernia without opening, if possible. If the hernia be still irreduci- ble, raise a small fold of the sac at the most dependent point and make a small opening, from which a little fluid will escape; introduce the director, and on this enlarge incision. - Division of Stricture.— If point of stricture is at €2ternal rºng, make the incision upward and outward; if at 27ttermal ring, insinuate the left index finger, and pass the 154 IX EY NOTES OF MEDICAL PRACTICE. finger mail under the stricture; pass the hermia knife flat, along the palmar surface of the finger, through the stric- ture, turn the edge of the knife directly upward, and cut a mere notch — one-eighth or one-quarter inch — by pré88wre of the knife, not by sawing motion. The hermia may now be returned by gentle manipulation. If the gut be gamgrenous or ulcerated, an artificial anus must be formed. If the omentum be inflamed, tie it with a stout ligature, and cut off the inflamed portion. - After reduction of the hermia, dress the wound aseptically, and apply compress and bandage. Provide for drainage. AIETIER-TREATINIENT. Rest in bed; liquid food till the bowels act; enema if the bowels do not act in ten days. Peritomitis, treat as from other causes. TREATMENT OF WOUNDS. (ANTISEPTIC METHOD–LISTERISM.) 1. Check haemorrhage by torsion, acupressure, forcipres- Sure, or catgut ligature, cut short. - 2. Cleanse wound of all foreign bodies. 3. Irrigate with antiseptic solution—Carbolic acid (1:40), JPrºce’s Lottom. 4. Provide drainage by carbolized horsehair, glass-silk, catgut, or perforated rubber tube. 5. Bring edges into exact apposition by carbolized silk or gut sutures. 6. Apply antiseptic dressing. - - The principles of wound dressing are—(1) make wound aseptic, and (2) preserve it so. The first principle may be carried out in operation wounds, by allowing nothing (fingers, instruments, etc.) to touch the parts unless previously disinfected by thorough washing in an antiseptic solution; the second, by use of some form of dressing which shall prevent access of un- purified air to the wound. Taking an amputation wound for illustration, the dressing may be efficiently made as follows: The wound surfaces having been thoroughly disin- fected, drainage provided, and sutures adjusted, the line of the wound, and half an inch or more of the surface on each side, are covered with Jodoform dusted on thickly; over this is placed a strip of aseptic oiled silk, perforated; directly on the oiled silk is placed Lister’s antiseptic gauze, eight layers wrung out of 1:40 Carbolic lotion, a layer of mackintosh, a top layer of dry gauze, and a bandage evenly and firmly applied. Drainage tubes are to be cut off flush with the skin, and secured, if in danger of slipping, by transfixing the end with a Safety pin, at right angles to the wound. - CONCUSSION OF THE BRAIN. 155. In a large percentage of cases there will be no necessity for changing the first dressing for four or five days, when drainage tubes may be removed, and the dressings repeated. In cases where wounds are not inflicted by the surgeon the same method of dressing is to be followed, after thoroughly disinfecting the wound by irrigation with Car- bolic lotion (1:20 or 1:40). Always provide free drainage. Where there is tension on wound edges, relieve by deep sutures adjusted at some distance. Use deep sutures, pref- erably of silver wire, fastened by means of buttons at each end. . . - - If, after removal of a tumor (e.g., mammary gland) deep cavities exist under the flaps, apply pressure by pads of gauze, so adjusted as to keep the deep portions in exact apposition. Complete immobilization of wound necessary. Other antiseptics may be used — Boracic, or Salicylic, acid; Boro-glyceride; Naphthaline; Corrosive sublimate (1:1000) or Terebeme. - Under this, or any efficient antiseptic method, wounds heal by first intention, patients are free from fever, and cases pursue an aseptic course.—Adams. CONCUSSION OF THE BRAIN. DIAGNOSIS.— Three stages. (1) Collapse. Feeble pulse; feeble respiration; pallor of skin; cold extremities; ilated pupils. Duration of first stage, half an hour to three hours or more. (2) Reaction (vaso-motor paresis). Patient restless, moans, turns on his side, draws up his knees, vomits. Can be roused, and will answer questions. I)wration — several hours. (3) Sleepy Stage. Pulse re- laxed, full, irregular; skin warm, even hot ; face flushed; pupils contracted. Patient overpowered with sleep, from which it is difficult to rouse him. Duration — a day to a week. At any time the presence of symptoms of non-symmetrical paralysis—weakness of one limb, one side of the face, a single eye-muscle — indicates more than concussion, there is laceration or contusion. Emuresis, or prolonged retention, has like significance. - PROGNOSIS.— Generally favorable. TREATMENT. Early, put the patient in a comfortable position, and maintain the heat of the body by warm blankets and other means. Give no stºmºtlants. In the third stage, give a non-stimulating diet; keep the patient quiet, and attend to the bowels and bladder. Remedies, Arnica and Opium. During compalescence, let the patient be very quiet, espe- cially avoiding all mental effort. - 156 E EY IN OTES OF MEDICAL PRACTICE. COMPRESSION OF THE BRAIN. DIAGNOSIS.— Symptoms: Complete insensibility; pupils, one or both, dilated; respiration labored, stertorous; pulse full and slow; skin warm and moist; sometimes strabis- mus; often hemiplegia; paralysis of sphincter ani; retention of urine. PROGNOSIS.— Grave. TREATMENT. Depends upon cause, whether depressed bone, extrava- sated blood, inflammation, Suppuration, or foreign body. Depressed bone calls for the use of the trephine (page 132); also, extravasation, when from injury and known to be accessible. In all cases—(1) dark room; (2) head high; (3) head shaved; (4) head cool; (5) low diet; (6) keep the bowels open, and watch the bladder. IDIFFERENTIAL IDIAGNOSIS. CONCUSSION. 1. Comes on instantaneously, and passes off gradually. 2. In sensibility, from which patient can be partly aroused. 3. Respiration feeble, like that of a person in a faint condition. 4. Pulse weak, irregular, and frequent. 5. Special senses dulled. 6. Pupils variable; usually sen- isitive to light. 7. Sformach, irritable; nausea or vomiting, with reaction. 8. Bowels relaxed, but sphinc. ters not paralyzed. 9. Bladder can expel water. COMPRESSION. 1. Comes on gradually, and tends to get worse. 2. IroSensibility, total, 3. Respiration stertorous, slow, and puffing. 4. Pulse full, slow, and labored. 5. Special Senses paralyzed. 6. Pupils, one, or generally both, widely dilated. 7. Stomach insensitive. 8. Bowels torpid, but sphincters may be paralyzed. 9. Bladder paralyzed; quent retention. conse: ABSCESS. LEADING IFEMIEDIES. Hepar sulph.--To avert threatened suppuration; or, when suppuration is inevitable, tumor hard, hot, swollen, with throbbing pains. Mercurius.--To avert suppuration. Glandular abscess, with nocturnal pain; tumor hard, shining, red, beating, and stinging. Belladonna, - Bright redness of affected part, burning, throbbing pain, erysipelatous appearance. - ABSCEss—LOCAL TREATMENT OF ULCERs. 157 Silica.-Fistulous openings, hard to heal; discharge thin and watery; abscess of bone; chronic abscess. Calcarea carb.-After suppuration completed, to pro- mote healing; strumous abscess. Sulphur.— Profuse discharge; tendency to recur; ema- ciation; hectic; strumous abscesses. SPECIAL REMEDIES. China. – During excessive discharge. Ledum.— From injuries or splinters. Arsenicum.— Fetid, Sanious discharge; or threatened gang reme. Mezereum.—Abscess in fibrous or tendinous structure, or from abuse of Mercury. Rhus tox. —Abscess of axillary or parotid glands; dis- charge thin and Samious. GENERAL VIEASURES. Remove splinter or other foreign body which irritates; cover with poultice until “ripe’’ for lancing; open abscess at most dependent point, as soon as pus has formed. All abscesses of size require drainage after incision. Deep- seated abscess, in proximity to, or underlying, important structures, blood vessels, etc., may be opened by Hilton's method, i.e., incise the skin, push the grooved director through the tissues toward the purulent collection; as soon as pus issues along the groove of the instrument, pass the dressing or polypus forceps; open them, and withdraw, thus making a free opening for the discharge, without endanger- ing the vessels. Labarraque’s Solution (Liquor Soda, Chlo- 7'inataº), one part to ten of water, is an excellent stimulant. for old abscesses and sinuses. - Chronic abscesses should never be opened except under strict antiseptic precautions. . In whitlow, or abscess beneath periosteum, lance clear to the bone, early. In thecal abscess, lance in the middle line, to avoid digital arteries, which run along the sides of the finger. - - Occasionally, cure of extensive abscess has followed repeated aspi- ration.—Ada?ns. - LOCAL TREATMENT OF ULCERS. - HEALTHY. Cleanliness; dress with Calendula lotion (3i to 3 ij warm water); protect from extermal irritation. - UNHEALTHY. Indolent.—Remove source of irritation; remove fungus granulations by knife or caustic Argentum nit.; stimulate the surface of the ulcer with Carbolic ointment (3.j to 3.j Vase- 158 KEY NOTES OF MEDICAL PRACTICE. line), or powdered ſodoform. For Cedema of edges, scarify, or use poultices. Apply rubber bandage. METHOD.--After the ulcer has been thoroughly cleansed (preferably by an antisep- tic Solution), if upon the leg, apply a bandage from the toes up, with just sufficient tightness for each turn to hold the one preceding without reverses; dress twice a day. Healthy action being established, treat as healthy ulcer, or, if the extent be large, hasten cicatrization by skin-grafting. Irritable.— Keep part at rest; apply hot water by com- press or irrigation; dress with &modyne poultices — hops or Lauda/nºwm, apply caustic thoroughly once; do not strap or bind. Inflamed.— Keep the part at rest and elevated; dress with Cyntiseptic poultices — Carbolic, Charcoal, Sodium and Zºne chlorides; avoid compression and caustics. Sloughing.— Occurs in debilitated and starved cases. Treat constitutional condition; build up general health by good, mourishing food, and tonics. LOCAL.— Same as for inflamed, unless very active, when Bromine (pure Bromine one drachm, to eight Ounces of water) may be employed. REMEDIES. Arsenicum.–Ulcer inflamed; raw-looking surface, which is red and hot, and bleeds on slightest touch; thin discharge, mixed with blood; edges of sore hard and irreg- ular; intense burning pain. Lachesis.-‘‘Irritable” ulcer; phageddºnic and slough- &ng ulcer; threatened varicose ulcer; large ulcers, tending to extend rapidly, Surrounded by small ulcerations or pus- tules; Surrounding skin presenting mottled, dark-blue, or purple appearance. Sulphur.—Excessive itching, burning, gnawing pains; bleeds easily; secretion thick yellow, or thin fetid; margins elevated, and surrounded by pimples; considerable adjacent swelling, and discoloration of skin. To begin the treatment of all chronic ulcers.—Jah?". Mercurius.-Deep ulcer; tendency to spread; discharge thin and offensive. Belladonna. –The Surrounding skin is the seat of Chronic inflammmation, of erysipelatous appearance. Rali bi- Deep ulcer of leg, with hard base and over- hanging edge. Mezereum.—“Mercurio-syphilitic ulcer of lower ex- tremity.”—Dunham. Sanguinaria.-Old, indolent ulcers, with callous edges, and ichorous discharge. Hamamelis.-Varicose ulcers. Phytolacca. – Ulcerations of mucous membranes. Scrofulous Ulcers. —Calcarea carb., Silica, Sulphur TREATMENT OF GANGRENE–CARBUNCLE. 159 TREATMENT OF GANGRENE. Traumatic. — In lacerated and contused wounds of ex- tremities; bones badly crushed; large vessels torn ; limb generally disorganized; if gangrene feared, ampulation should at once be practiced. In case of gangrene of an extremity, after attempt being made to save it, amputate at once, and in all Varieties of traumatic gangrene where the limits of the disease can be well defined, and the whole eactremity is involved. Super- ficial sloughs are not to be taken for entire destruction of the limb. The extent of destruction of tissue being small, bring about speedy separation of slough by poultices and hot dressings. Remove dead pieces, as they loosen, with scissors and forceps. During sloughing, use locally antisep- tic poultices, and carbolized hot-water dressings. During local reaction, no pressure is to be used on injured part. Gangrene from extreme heat, cold, or escharotic, treat on expectant plan till the line of demarcation is formed; then amputate, if entire thickness of the limb is involved. Gangrene from infiltration of urine in perimeo, imme- diately make free incisions to relieve tension, and give free vent to collections. • - - Gangrene from arrested circulation, after ligation of arterial trunk, apply warmth by cotton, etc., and keep up patient's strength until collateral circulation is established. CARBUNCLE. LEADING REMEDIES. Arsenicum.— Malignant carbuncle; great prostration and restlessness; small, irregular pulse; cold sweats; diar- rhoea and fever. Bryonia.-‘‘Hastens the process of suppuration, reduc- ing the period many days.”—Jahr. Belladonna. – Smooth, bright-red swelling, tense skin. Apis. – For extension of erysipelatous swelling. Lachesis.- Parts look purplish; low, inflammatory con- dition; blood-poisoning. Arnica.-In repeated doses, early, sometimes disperses. Silica.-After Suppuration, to check excessive ulcera- tion, and promote healthy granulation. & GENERAL MEASURES. A commencing carbuncle may be successfully aborted by injecting into its center, by hypodermic syringe, several drops of pure Carbolic acid. Iodine, locally, has dispersed. Also lime water and Camphor. Early strapping beneficial; encircle with tightly 160 REY NOTES OF MEDICAL PRACTICE. applied, broad, adhesive straps, which will draw the edges together; remove straps daily after the discharge has begun, and cleanse the surface; keep well poulticed ; not necessary to imcise unless the tension is extreme. After suppuration is established, dress with Carbolic ac. and Glycerine ; if gamgrene threaten, dress, with powdered charcoal, frequently renewed—every three to six hours. Never use the knife in carbuncle complicating diabetes. DISSECTION WOUNDS. Suck the wound immediately, and apply Carbolic acid, or cauterize with Nitrate of silver. If the wound becomes inflamed, dress with hot poultices; internally, Arsenicum ; if great prostration, give Carbonate of Ammonia. INSECT STINGS. For stings of bee, mosquito, wasp, etc., apply Agua. ammonia, or tincture of Ledum pal; moist clay poultice, if nothing else at hand; remove sting when visible. SNARE BITES. Tie a broad ligature tightly about the limb, above the wound, so as to check circulation; suck the wound, and cau- terize with Nitrate of silver, strong Carbolic acid, or a nail heated red-hot. . Apply ligature, and, as Soon as possible, inject with hypodermic syringe a solution of Permanganate of potash, (1:100), as nearly in line of penetration of the serpent’s tooth as possible. - The Emperor of Brazil has recently bestowed on Dr. Lacerdo $20,000, for his discovery of this antidote. Stimulate by injecting Ammonia into the veins, or by its internal administration. Keep the patient quiet, and con- serve the strength. Artificial respiration must be employed if the breathing fall to ten per minute. - The ligature must be occasionally slackened, that the poison may but slowly enter the system, and the limb not suffer from complete stoppage of circulation for too long a time. SPRAIN. Give the part absolute rest; immerse immediately in hot water, until pain and swelling are reduced; after- Ward, dress with cloth wrung out of lotion of Rhus, Acomºte, Arnica, or Hypericum, and covered with oil silk. After the pain has been lessened by immersion in hot water, envelop the part in absorbent cotton, and apply a bandage firmly, exerting through the cotton uniform elastic compres- Sion of the parts. HYDROPHOBIA — BURNS AND SCALDS. 161 Arnica.- Contused appearance. JRhus.--When tendoms are involved. Aconite.—Heat, redness, and swelling. Hypericum.—Nerves involved, or lacerated. HYDROPHOBIA. Belladonna. —As soon as a person has been bitten, ad- minister Belladonna in a low dilution, and keep him under its influence for at least six weeks. Also administer it if the characteristic convulsions set in at any time, with great burning and accumulation of frothy mucus in the throat, constricting sensation when attempting to swallow, redness and bloatedness of the face, foaming at the mouth, and tetanic convulsions. It is only in the largest quantities that its remedial power has been most frequently observed.—Hughes. - Stramonium.—Convulsions attended by frightful dreams; agitated sleep; sudden shrieks; insensible and dilated pupils; disposition to bite and tear things with the teeth. g - Reputed a specific for the disease in China.-Hughes. Scutellaria.-Nightly restlessness; frightful dreams; rapid and unequal action of the heart, with pain, tremu- lousness, and twitching of the muscles. Has been found very successful in many cases, both as preventive and curative.—Lawrie. GENERAL MEASURES. Immediately suck the wound (do not let it come in con- tact with an abraded surface of the mouth), wash it out with a stream of Warm water and apply freely pure Carbolic acid; Or, actual cauté)'ſ may be applied. Give Belladonna treat- ment. IN ATTACK.—Vapor bath, or Turkish bath, temperature 107° F., said, to have been successfully used. Give the patient bits of ice. BURNS AND SCALDS. CLASSIFICATION. FIRST DEGREE.—Hypera-mia; erythema; irritation or inflammation of the skin, without vesicles. SECOND DEGREE,-Vesication; inflammation of the skin; formation of vesicles and bullae. THIRD DEGREE.-Eschars; gangrene, superficial or deep; involving the skin or any other subcutaneous tissues; car- bonization of a part, or of the entire body. * PROGNOSIS.— If one-half, or even one-third, of the Surface is burned or scalded, death is inevitable. In other 11 162 KEY NOTES OF MEDICAL PRACTICE. cases, result depends on location, intensity of heat, nature of medium, age, temperament, and constitution of patient. TREATMENT. LOCAL. —Apply immediately one of the following: Carbolized Vaseline (Carbolic acid five per cent.). Carbolized Olive Oil (11 parts oil to 1 part liquid Car- bolic ac.). I'low' and lard, equal parts worked together, White lead paint. Equal parts Lönseed oil and Lime 200ter. . Bºcarbonate of soda. Fine wood charcoal. Dress to exclude air and keep up warmth of the part. Probably no dressing equals the carbolized Vaseline. TJse that which can be most quickly obtained. Spread on a thick layer, cover with gauze and Cotton-Wadding, and bind lightly. Leave first dressing on as long as possible — until offensive nature of discharge or discomfort demand its removal. Dress in such a way as to facilitate future dress- ings bit by bit. Do not expose too large a surface at once. Blisters should be pricked, and contents evacuated, leaving the skin as a protective covering. In dressing, irrigate with carbolized water, a drachm to the pint. Iodoform, sprinkled on, relieves the pain; put other dressing over it. In extensive burns or scalds, use continuous tepid bath, 90° to 100° F. In burns or scalds of the extremities, immersion of the part in a tepid bath gives great relief. During cicatrization, prevent deformity by position, attained by splints and mechanical appliances. Employ skin-grafting to promote healing of ulcers. GENERAL.—Treat shock by artificial warmth, rest, and repeated doses of Camphor. For depression, Ammonia as a stimulant. In exhaustion from profuse Suppuration, give nourishing food. - Rhus. – Burns of first and second degree. Rali bi...— Indications of ulceration of duodenum. Cantharis.-Vesication; Scanty and high-colored urine. HAEMORREHAGE. Ligature.— Cut down upon the bleeding point, and tie above and below the wound. In case this would involve a large and deep incision, tie “in continuity.” Materials : silk, hemp, catgut. Instruments : forceps, retractors, directors, artery forceps, tenaculum (sometimes, aneurism needle). Secure the vessel, tie with reef knot, and, unless catgut used, one end of the ligature must be left hanging out of the wound. The ligature must be smooth, round, strong, and well waxed. IHAEMO R.R.H.A.G E — EPISTA XI.S. 163 Torsion.— Draw out the vessel and make three or four sharp rotations of forceps. In large arteries continue the rotation till sense of resistance has ceased, but do not twist off the ends. In small arteries the number of rotations is of no importance, and ends may be twisted off or not. Acupressure.—Compress vessel between needle and loop of wire, like the common hare-lip suture. In arteries of medium size, the needle may be removed in four hours. Adapted to scalp wounds, and when caricose veins burst. Cautery. — For haemorrhage from the neck of the womb after operation. Compression.— By tourniquet, Spanish windlass, or digital. CAROTID.— Press along immer edge and lower half of sterno-mastoid muscle. - - SUBCLAVIAN.— Push firmly with the thumb in the sub- clavian triangle behind the sterno-mastoid. BRACHIAL.-Inner border of coraco-brachialis and biceps. FEMORAL.— Under Poupart's ligament, midway between anterior superior spinous process of the ileum and the pubes. ABDOMINAL AORTA.— Short distance above and to the left of the umbilicus. - In wounds of the palm, or where many inosculating vessels are injured, pack the wound tightly with picked lint or other available substance, and apply a firm bandage. Put the limb upon a splint to insure perfect rest. Flexion.— In wounds below the showlder, put arm-pad or roll high up in the axilla, and bind the arm to the side. In wound of palman arch, put compress in bend of elbow, flex the forearm on the arm, and promate the hand. In haemorrhage from planta' vessels, put a pad in the popliteal space, flex the leg on the thigh, and the thigh on the abdo- men. Or, hang the leg, in the bend of the knee, over a sharp chair back. Styptics.-Ice, #. directly to bleeding surface. Persulphate of iron (Monsel's solution); Tannic acid, Gallic acid, Małºco, Alum. Water 120° F. GENERAL VIEASU’ſ RIES. For faintness and weakness caused by loss of blood — horizontal posture; absolute rest; Ammonia; Ether; wine. Esmarch's bandage, to drive blood from limbs, to vital centers. Transfusion. EPISTAXIS. When slight, apply pressure to cheeks, at their junction with the alae nasi; use nasal douche of hot water, 110° F.; o'-' º ..) || || - * Y ** , * 3 5 ° 4’3 - J S - y - - - y in - Y 164: REY NOTES OF MEDICAL PRACTICE. ice to the nape of neck; use Tammim as snuff; use styptics in solution — Alum, Iron persulphate. Enjoin quiet on the part of the patient; keep the neck straight. Plug the nostril if the haemorrhage is severe; pass a loop of double thread, by means of a catheter or Bellocq's Camula, along the floor of the nose to the pharynx, seize the loop and fasten it to a plug of lint or cotton already attached to a string, which is brought out of the mouth and retained for withdrawal. By means of the double thread in the nose, draw the plug into the posterior mares, and tie the ends of the thread over a plug inserted into the mostril in front. Remove by the string through the mouth when no longer needed. TJ RETHRAL HAEMORRHAGE. Locally, use cold applications, hot injections, Hamamelis, or, introduce catheter, and apply compression by means of a bandage. If from an external, longitudinal wound, make close coaptation by fine sutures, and draw the urine with a small catheter four or five times a day. In transverse wound, after haemorrhage is checked, introduce Sound at intervals during the healing process, to prevent stricture. In haemorrhage into tissues about deep urethra, make free incisions to relieve tension, use antiseptic irrigation, and keep urethra patent by use of Catheter or sound. RECTAL HAEMORREHAGE. When beyond control by use of ordinary remedies, if from a vessel within reach, apply ligature; if general and styptics and hot water fail, use tampom. To plug properly, take cup-shaped sponge or wad of Cotton, pass a stout double ligature through the middle, and pass this into the bowel beyond the source of the hamorrhage. Pack the rectum below with pledgets of cottom, and then draw threads tight, and fasten them over a compress of cotton placed externally, thus making even pressure in all directions. A stiff catheter or tube may be placed before plugging, to allow escape of flatus. . TJTERINE HAEMORREHAGE. Method of plugging vagina. – Put patient in Sims' position; with left forefinger, or Sims' speculum, retract posterior vaginal wall; with pledgets of cotton, or free end of roller bandage, pack vagina posteriorly to cervix, then anteriorly, then centrally, until firmly filled by plug, taking care not to obstruct urethra. After sufficient time has elapsed, remove piecemeal, patient in same position. & gº VENIESECTION — SHO CIX. 165 Or, introduce large, moist sponge through a speculum. Do not let tampon remain without change more than three or four hours. - VENESECTION. Instruments.- Bleeding-tape, or bandage; bowl; lan- Cet; pad; sponge and water. Patient recumbent. Apply tape to middle of upper arm, tight enough to congest veins, but not to affect pulse. Hang the arm down a little while; then choose the spot, usually the median basilic vein (look out for brachial artery); pass the lancet gently and obliquely into the vein, and enlarge the opening without deepening the incision. If necessary, make the patient work his hand, opening and shutting it; or grasp some small object. When sufficient blood has been withdrawn, remove the bandage from the arm, apply a pad to the wound, and bandage it by figure-of-eight. Wear the arm in a sling for several days. SHOCK. I loosen everything about the neck and chest that can impede the respiration ; body recumbent, head low. Maïn- tain temperature of body — warm room; warm blankets; hot bottles to the extremities, between the thighs, and in the axillae; hot compress over cardiac region; warm affusion to head; frictions. If much blood has been lost, and the vaSO-motor mechanism is not paralyzed, employ transfusion. Stimulants, not too freely; brandy, Ammonia, Ether. Do not pour fluids down a patient who cannot swallow. Ether has been used with great success. Inject, hypodermically, thirty minims every five or ten minutes until the patient is able to swallow, then substitute brandy and Ammonia, by the mouth. In the absence of Ether, employ intra-venous injection of Ammonia, ten minims of liquid Ammonia fortis — degree of dilution not material. Digitalis.-Ten minims, hypodermically, as a cardiac stimulant, very beneficial. If there is a mangled limb to come off, and shock is slight, give Ether, and operate. If the shock is so grave that reaction is doubtful, wait several hours till the pulse begins to regain strength. If the temperature is below 96° F., do not operate. When reaction sets in, give warm, mourishing, liquid food, small quantities, frequently repeated — coffee and Scalded milk, equal parts; milk, beef tea, soup. I66 Ix EY NOTES OF MEDICAL PRACTICE. ADMINISTRATION OF ANAESTHETICS. A. C. E. Mixture. Alcohol (by measure), - - - - - 1 part; Chloroform ‘‘ - - - - - - 2 parts; Ether & 4 - - - - - - 3 parts. Use much as you would Chloroform. Make it afresh just before it is required for use. This is the favorite anaesthetic at Guy's, and at most of the London hospitals. It is almost as safe as Ether, while being free from many of the latter's objectionable qualities. - - - Chloroform.— Commence gently; limit dose to smallest quantity capable of producing insensibility — fifteen drops on a towel to begin with; permit free access of air. Ether.—Two drachms to begin; no air; push vigor- ously, especially in the stage of excitement. Precautions.— Do not push an anaesthetic too much at first; watch the quantity used; allow plenty of air with Chloroform ; have provision for admitting a free supply of fresh air; carefully watch the pulse and respiration,-- especially the latter; have dressing forceps ready to grasp the tongue. Do not let a flame come near Ether vapor. TREATMENT OF DANGEROUS SYMPTOMS. Give fresh air; pull the tongue well forward; if any difficulty, the tongue may be drawn from off the glottis by placing the thumbs alongside of the nose, and the index fingers behind the ascending ramus of the lower jaw, and drawing it forward; clear the throat of blood, or vomited matter; hot affusions to the head; invert the patient; arti- ficial respiration; inhalations of Nitrite amyl. Galvanism — One pole on the throat, near the phrenic nerve, the other at the pit of the stomach; or, through the skin at the sides of the nose. - LOCAL ANAESTHESIA. Cocaine.—A solution of the Hydrochlorate of cocaine up to five per cent. can be made without the addition of an acid. The solution is always cloudy, but when filtered becomes as clear as distilled water. The addition of an acid is to be avoided, as even a very small quantity causes a strong burn- ing Sensation. For operations on the eye use a two-per-cent. Solution. With the patient's head thrown back a little, depress the LOCAL AN AESTEI ESIA — IH ARIAE-LIP. 167 lower lid while the patient looks up. Into the cul de Sac thus formed, instill two minims of the solution. Now have the patient alternately look down and up two or three times, when the cornea will become covered with the Solution. For the removal of foreign bodies, one such instillation is generally sufficient, anaesthesia being sufficiently complete at the end of from three to five minutes. - If more complete anaesthesia is desired, repeat this in- stillation once or twice, at intervals of from three to five minutes. Three instillations will produce anaesthesia lasting for about twenty minutes, sufficient for almost any opera- tion. - Use in almost all operations on the eye – removal of for- eign bodies, cauterization of corneal ulcers, puncture of cornea for paracentesis, tattooing cicatrices, iridectomy, ope- ration for pterygium, and even for removal of Cataract. In many minor surgical operations, also, it is all-sufficient. Inject under the skin four minims of a four-per-cent. Solu- tion, and repeat as necessary. Avoid producing Constitu- tional symptoms. - Local anaesthesia may also be produced by the applica- tion of two parts of crushed ice to one part of salt, in a gauze bag. Do not freeze the part. Ether spray is also effective. HARE-LIP. Best time to operate, third to fifth month of infancy. Contra-indicated— during dentition or ill health. Chloro- form unnecessary. Apply small bag of pounded ice and salt, or inject a solution of Cocaine into the edges of the fissure, till local anaesthesia is induced. Child held in assistant's lap. Secure the limbs by rolling him lightly but firmly in a shawl. Assistant to check hamorrhage by holding each side of the upper lip between finger and thumb. Begin by sepa- rating, with the knife, the two sides of the lip from the jaw subjacent, unless the former structures be already very free. Then pare the edges of the cleft. Remove enough tissue, especially from the apex of the cleft, and the junction of the cleft with the edge of the lips. Coapt the edges, insert two “hare-lip’’ pins; enter and exit one-quarter inch from the fissure; pass deeply, nearly reaching mucous membrane. The lower one secures the coronary artery. Secure with hare-lip suture. Interrupted wire suture at red border of lip. Sharp ends of pins nipped off. Pieces of lint placed beneath the ends of the pins. Strapping, broad at ends and narrow in middle, brought across lids. All pins must be removed on third day, very gently, lips being well supported at the time, and strapped immediately afterward. Instead of pins, the interrupted suture of wire, aseptic silk, or gut, may be used. 168 ISIEY NOTES OF MEDICAL PRACTICE. NAEW US. Capillary navi may be successfully treated by successive paintings with liquid Carbolic acid, Nitric acid, Lunar caus- tic, or by puncture at various points with a hot needle. More extensive forms may be treated by (1) compression; (2) ligature, which should be subcutaneous, to avoid Scar; (3) e.vcision, (4) by ligature of vessel of supply. Injections into navi should never be employed. INTUSSUSCEPTION. Plumbum.—Colic and fecal vomiting. Opium.— Meteorism, and stercoraceous vomiting. Aconite, Belladonna. —To obviate inflammation. . Nux v.–To correct irregular and excessive peristalsis. G.E.N.E.R.A.T. TREATINIIENT. Early in the Attack. — Place the patient on his back, hips elevated, shoulders low; introduce a long tube into the rectum, passing it as high up as possible, and slowly inject Zarge quantities of warm water or olive oil. As the fluid is Coming away, manipulate the abdomen with the hands, so as to move coils of intestines. Repeat the entire process several times, if necessary. Sometimes it is well to anaes- thetize the patient preparatory to operation. Also try invert- ing the patient. In children, inflate the bowel with air until the abdomen is much distended. Keep stimulants at hand, as syncope Sometimes occurs. . In cases where the above measures fail, and the diagnosis of obstruction is clearly made, perform laparotomy with antiseptic precautions. Operation, preferably in median line, consists in exposing peritoneum by incision of three to five ingles, checking all haemorrhage, opening peritoneum, Searching for obstruction, and relieving it according to its nature. THORACENTESIS. Indications.—Amount of effusion great, with dyspnoea; old effusion, which remains stationary. OPERATION. - - Use aspirator; needle moistened with oil; slight prelim- inary incision. Introduce near the axillary line, in the fifth intercostal space on the left side, the fourth on the right, or Seventh, near the angle of the Scapula, posteriorly. Insin- uate the needle with a twisting motion, near the upper bor- der of the lowermost rib of the two. Then plunge the needle Smartly through the pleura, turn the cock of the aspirator, and collect the fluid. PARACENTECIs ABDOMINIS-HAEMORRHOIDS. 169 Dangers. – Wounding intercostal vessels, lung, or dia- phragm; rupture of pleura or capillaries by excessive suc- tion with aspirator; admission of air. PARACENTECIS ABDOMINIS. Indications.— Called for if the amount of effusion is SO great as to seriously embarrass respiration or the heart's action. - OPERATION. Make ink-mark exactly in median line, midway between umbilicus and pubes. Turm the patient on his side, near the edge of the bed. Bladder must be empty. Ascertain by percussion the presence of fluid at the spot to be pierced. Apply a broad flannel belt, or a sheet, around the abdomen, the ends crossed behind, and held by an assistant, who gradually draws it tight as the fluid is withdrawn. Tap through a hole cut in the cloth at the proper point, Incise the skin at point selected, and introduce the trocar. Draw off the fluid slowly. When all is out, seal the wound with plaster, and pin the band tightly around the abdomen. Dangers. —(1) Haemorrhage, from not keeping to mid- dle line; (2) wound of bladder, from not emptying it; (3) wound of bowel, from not tapping in a thoroughly dull spot, or from plunging the trocar too deeply; (4) fainting. PNEUMATIC ASPIRATION May be practiced in any part of the body, and is a safe procedure as long as only the fine needle (No. 1) is used. Aspiration with the larger needles is to be practiced with the same caution as tapping with the trocar, the risk of aspira- tion equaling that of tapping when the larger needles are used. HAEMORRPHOIDS. Internal.— Of capillary variety — viz.: elevated thick- enings of the mucous membrane — best treated by applica- tion through a speculum, with a wooden spatula or a glass rod, of pure Nitric acid. Forcible dilatation of sphincter occasionally cures by relief to circulation during partial paralysis of sphincter following dilatation. Internal haem- orrhoids, more or less pendulous, are best treated by (1) In- jection of mixture of equal parts of Glycerine and Carbolic acid. To do this safely, clamp the base of the pile with the forceps, so as to interrupt the circulation; with hypodermic syringe, charged with the mixture, insert the needle into the substance of the haemorrhoid, and inject M. V ad x. Repeat + 170 KEY NOTES OF MEDICAL PRACTICE. the injection at intervals of three or four days until the tumors shrivel and slough away; (2) Ligature. Patient under Ether; dilate the sphincter, forcibly seize haemorrhoid with forceps; with curved scissors dissect the hamorrhoid slightly from the mucous membrane from below upward, thus avoiding vessels which always enter a pile from above; transfix the pile with a threaded needle, and tie firmly on each side: repeat the process on all internal piles. Confine the patient strictly to bed for a week. Ligatures come away generally in four to five days. Patient should take no exercise of amount for ten to fourteen days. External haemorrhoids, when seen early, i.e., during first forty-eight hours, should be incised, and the clot of extravasated blood, which gives pain by causing tension of tissues, turned out. Always incise in line radiating from anal center. If ancient, and source of annoyance, remove by Scissors, clipping away tab of thickened integument in line radiating from anal center. - ANAT, FISSURE. When productive of slight degree of suffering, may be treated by application of Jodoform, in powder or supposi- tory. A single application of Nºtrate of Silver to a fissure will sometimes suffice. Severe forms only amenable to treatment by incision or forcible dilatation. To incise, expose the part thoroughly and cut through the base of the fissure deeply enough to divide the super- ficial fibers of the sphincter muscle directly under it, then apply Iodoform, cottom pad, and T bandage. To dilate, put the patient under Ether, insert the thumbs into the rectum back to back, and stretch the sphincter until the thumbs touch the tuber ischii, or the sphincter is thoroughly relaxed. Dress as above. RECTAL STRICTURE. Gradual dilatation with bougies at intervals of three or four days, Safest but slowest method. If the stricture be thin and bridle-like, nick the edge of constriction at three or four points in its circumference, and pass a bougie. Posterior rectotomy to be employed if stricture irritable and of small caliber. Patient under Ether; with straight, probe-pointed knife, cut through the stricture and sphincter toward the coccyx, keeping the incision strictly in the median line. Keep the patient recumbent, pack the wound With antiseptic cotton, and, as it heals, pass a bougie to preserve the caliber of the rectum. RECTAL FISTULA— RETENTION OF URINE. 171 RECTAL FISTUL.A. Three Varieties — result of abscess in submucous tissue of rectum — internal, external, and complete. INTERNAL should be made complete by passing a probe, bent into hook shape, into rectal opening and making it. project the integument, cut down Cn the end of the probe, and operate as for complete fistula. ExTERNAL should be made complete by passing director into external opening to the thinnest portion of the rectal wall, determined by the finger in the rectum, and forcing the director through into the rectum. - CoMPLETE fistula may be treated by incision on director, or, in timid patients, by elastic ligature. To incise, put the patient under Ether, pass a grooved director through fistula, bring the point out at the anus, and cut all overlying tissue; slit up sinuses leading into the fistule, pack the wound with oakum for first forty-eight hours, and then dress with Iodoform, keeping the patient recumbent until the wound is fairly filled by granulations. To ligature, take a solid rubber cord, 36 inch in diameter, pass a silk cord through the fistula by means of an eyed probe; draw the rubber cord through double, pull it tense, and tie tightly, overtying the rubber knot with silk to pre- vent slipping. Under this method the patient may move about. COCCY GOD.INIA. If obstimate, divide subcutaneously all muscular and ligamentous structures from the borders and tip of the coccyx. If the coccyx be luxated and displaced, or carious, remove it. RETENTION OF URINE. From Stricture. — Put the patient in a warm bath to relax spasm; pass a small catheter, or filiform bougie, which use as a guide for tunneled catheter. If filiform bougie or small catheter passes, tie in for continuous dilatation, re- placing it by larger size in twenty-four hours. If stricture is impassable, relieve the bladder two or three times in twenty-four hours by aspiration, Supra-pubic. After two or three days, attempt the passage of instrument again. If the instrument cannot be passed, and fistulous opening exist, perimeal section should be performed. . From Enlarged Prostate.— Pass a soft rubber cathe- ter, Mercier's elbowed Catheter, or over-curved gum-elastic catheter. If retention has existed for some time, do not empty the bladder at once, but at the third or fourth cathe- 172 IX EY NOTES OF MEDICAL PRACTICE. terization, after which keep the bladder clear of residual urine. When the bladder is completely closed by hyper- trophy of prostate plus inflammation, supra-pubic aspira- tion may be practiced twice Ör thrice daily, until the catheter may be passed. If catheterism impossible, supra-pubic puncture and introduction of perman mt tube relieves retention, and, when done early enough, is followed by subsidence of ºrostatic over growth.-Auams. CIRCUMCISION. Draw the foreskin well forward and hold it by compres- sion between the blades of forceps applied where section is deemed best; cut off the portion included in the forceps; split up the mucous membrane to the corona, turn it back, trim the edges, and unite them to the skin by numerous fine sutures of catgut. In infauts sutures are unnecessary. Dress by enveloping the part in a strip of sheet lint, which should be kept moist with 1:40 Carbolic lotion. Treat haemorrhage by torsion if not spontaneously checked. Local anaesthesia may be produced prior to operating by injecting a four-per-cent. Solution of Cocaine. Inject four minims at four different points — on the dorsum, near the franum, and at each side — in all, sixteen minims. In ten or fifteen minutes anaesthesia will be complete. GANGLION. Rupture it by placing the patient's wrist on your knee, steady it with your fingers while you squeeze the ganglion, with the ends of both your thumbs, against the ridge of bone beneath. Other methods failing, employ subcutaneous puncture, and follow either method by pressure with pad and bandage. Bl]NION. Remove pressure of boot, which is always the cause ; restore toe to natural position by mechanical contrivance. Use corn plaster, soap plaster, arnica plaster. If it dis- charge, use stimulating dressings. When inflamed, poul- tices or formentations. CORNS. Soak the foot in a warm bath half an hour or an hour; extract the hard head with the finger mail, or a blunt instru- ment; dress with Armºca loſion; wear during the day armic: plaster, and felt, with a hole in the center. Repeat this several days, and wear easy shoes, and there will be no more return. * IN• GROWING TO E N AIL — SYPHILIS. 173 IN-GROWING TOE NAIL. With the point of a penknife insinuate a bit of cotton beneath the side of the nail, and between the edge of the flesh and the overlapping nail. Poultice and rest if much inflammation. If scraping nail down the middle fails to relieve, pare away overlapping flesh — remove underlying portion of nail; or, these measures failing, remove entire mail by avul- Sion under anaesthetic. THE WENEREAL. SYPHILIS. Definition.—A specific, infectious disease, having a period of incubation, and characterized by the appearance of a chancre, then by eruptions on the skin and mucous membranes, subsequently by chronic inflammations of the cellulo-vascular tissues and the bones, and finally by small turnors, or gummata. One attack affords protection against a second. The initial lesion is always a chancre, whether the source of infection be a chancre or a secondary lesion. A perfect recovery from syphilis is possible (Keyes). Initial Lesion.—Varies. May be hard, desquamating papule, a raw erosion, or a superficial ulcer. %. chancre—generally solitary, shallow; borders adherent and sloping; base indurated; floor grayish; the secretion thin, Scanty, non-purulent. It is indolent, and generally painless. Period of Incubation.—A chancre (if not modified by treatment) will usually be followed by secondary symptoms within fifty days, and always within six months. It may be as short as ten days. PRIMARY STAGE. T.E.A.DING RENTEDIES. Mercurius sol.—This is the only remedy worthy of confidence in the treatment of recent, uncomplicated cham- cre. Chancre with red edges, lardaceous bottom, painful and readily bleeding; indurated base and margin. DOSE. — 1X to 6x trituration, a grain night and morning. Stands in the front rank.-Franklin. Enjoys universal confidence.—Hughes. Only remedy for the uncomplicated forms.-Baeh)". Mercurius cor. — For phagedænic chancre; ulcer secreting thin, ichorous pus. Secondary symptoms make early appearance. 174: IXEY NOTES OF MEDICAL PRACTICE. Mercurius iod.— Painless chancres; glandular system largely involved; inguinal glands large, swollen, but not inclined to suppurate. - Arsenicum.–Gangrenous chancre. Ulcers with florid, unhealthy granulations; or, Secreting a watery, corrosive, offensive fluid. Only efficient remedy.—Baehr. In gangrenous, never fails.-Jahr. Nitric ac.— For chancre of some weeks' standing that has been treated with large doses of Mercury. Ulcer bleeds easily and profusely ; pale, flabby, prominent granulations; fungous growths; corrosive discharge. . Arsenicum iod.— For swelling of inguinal and axillary glands, threatening Suppuration. Excels all other remedies in the rapid cure of venereal bubo.—H Noah, Måröm. - BUBO. Requires the same treatment as the chancre from which it proceeds. For acute bubo, Mercuriºus sol. ; for indolent bubo, Mercwrius Žod. . LOCAL.- Observe strict cleanliness of the parts. To pri- mary sore, apply simple lint, soaked in cold or tepid Calen- dula lotion, renewed every three or four hours. Chloral hydrate Solution, twenty grains to 3.j Aqua, hastens healing process. If discharge fetid, sprinkle with powdered Chlorate of potash, and cover with wet compress; renew frequently. For sloughy ulcers, apply slightly caustic solution Nitric acid, or Carbolic acid. * * GENERAL.—Avoid stimulants, excitement, over-exertion, and excesses of all kinds. Let the surroundings be the most favorable, hygienically, that can be procured. Have fresh air, moderate out-door exercise, and a plain diet. Encour- age in the patient hopes of ultimate recovery. Frequent bathing of the skin is very beneficial. TABLE GIVING USUAL PERIOD OF DEVELOPMENT OF LESIONS. LJSU AI, MAY DELAY I.ESION. NO. DAYS, - AS LONG AS 1. Roseola . . . . . . . . . . . . . . . . . . 25 to 45 . . . . . . . . . . . . . . . . . . . . 12 months. 2. Lichen . . . . . . . . . . . . . . . .28 to 65 . . . . . . . . . . . . . . . . . . . . 12 * { 3. Mucous patches ... . . . . . . . 30 to 70 . . . . . . . . . . . . . . . . . . . 18. “ 4. Sec'd aff, fauces . . . . . . . . . . 50 to 70 . . . . . . . . . . . . . . . . . . . . 18 “ 5. Vesic. erup . . . . . . . . . . . .... 55 to 90 ... ... • * * * * * * * * * . . . . 6 § { 6. Pustular . . . . . . . . . . . . . .45 to 80 . . . . . . . . . . . . . . . . . . . . 4 &S 7. Rupia. . . . . . . . . . . . . . . . . . . . 7 mS. to 2 yrs............. 4 { % 8. Iritis . . . . . . . . . . . . . . . . . . 2 to 6 months........ . . . . 1 year. 9. Sarcocele . . . . . . . . . . . . . . . . . 6 to 12 { % tº . e s tº : * * * * * * * = 3 years 10. Periostitis . . . . . . . . . . . . . . . . 4 to 6 “ . . . . . . . . . . . . 2 “ 11. Tuberc. erup. . . . . . . . . . . . . . 3 to 5 years . . . . . . . . . . . . . 2. “ 12. Serpig. erup. . . . . . . . . . . . . . . 3 to 5 “ . . . . . . . . . . . .20 “ 13. Gummy tumors. . . . . . . . . . . 4 to 6 “ . . . . . . . . . . . . 15 “ 14, Onychia. . . . . . . . * * * * * * * * * g = e 3 to 6 “ . . . . . . . . . . . . 22 “ 15. EXOstosis . . . . . . . . . . . . . . . . 2 to 6 “. . . . . . . . . . . . . 20 { % 16. Ostitis . . . . . . . . . . . . . 2 to 4 “ . . . . . . . . . . . 41 § { 17. Destruct. vel. pal . . . . . . . . 2 to 4 “ . , 20 “ SYPHILIS. 175 No one who has had syphilis should marry until he has . been free from all symptoms for a period of at least three years. CHANCRE. CHANCROID. 1. A general blood-disease. 1. A Vocal tissue-disease. 2. From inoculation with syphº- 2. From inoculation with Chan- litic nyirus. croidal virus. 3. Incubation, ten to sixty days, 3. Incubation, none. Ol' DYOl’é. • ‘ 4. Auto-inoculation impossible. 4. Amºnoculation always pos- Sæble. - 5. Lesion, usually an excoriation 5. Lesion, a rapidly spreading, or Žn durated shallow ulcer. soft nlcer. 6. Number, usually single, 6. Number, often multiple, 7. Secretion scanty, Serous, San- 7. Secretion, creamy, free. guinolent, 8. Edges slanting, adherent. 8. Edges, perpendicular or un- - dermined. 9. Generally painless. 9. Often painful. - 10. Phagedæna very rare. 10. Phagedaema not uncommon. 11. Bubo invariable; seldom sup- 11. Bubo in about one-third the purates. cases; often suppurates. 12. Second attack very rare. 12. Second attack possible. 13. Local treatment unimportant. 13. Local treatment highly im- portant. SECON DARY AND TERTIARY. LEADING REMEDIES. Mercurius.-Feverishness; rash; sore throat; rheuma- toid pains, aggravated by rest and the warmth of the bed; erythematous, papular, and Squamous eruptions; Superft- cºal ulcers in the throat; iritis; fauces and tonsils swollen, inflamed, and ulcerated; emaciation, with slow, hectic fever. Rali hyd.- For secondary and tertiary forms, particu- larly in those who have been over-dosed with Mercury. Nodes: gummata; erythema; tubercular skin eruptions; ulcers on tonsils; periostitis; coryza; iritis; ulceration of nose, mouth, or throat, with corrosive, burning discharge; Pain in nodes quickly relieved, and the nodes soon disap- pear. DoSE.—Give one to five grains of the crude drug ter die; in obstinate cases, fifteen to twenty grains ter die. We have nothing to take the place of the Iodide of potash in ter- tiary syphilis.—Hughes. - No remedy *. this as an antidote to the syphilitic poison in the secondary, and especially in the tertiary form of the disease.-- Franklin. - Aurum.–Syphilophobia; ozaema, with caries of nasal and facial bones; ulcers of nose and mouth, with fetid discharge; nodes of cranial bones; sarcocele; lupus; syphil- itic rheumatism; suicidal melancholia. Covers nearly the whole field of the tertiary, with its cachexia.- Hughes. - Nitric ac.— Ulceration of the mouth, and cracks about the commissures of the lips. 176 REY NOTES OF MEDICAL PRACTICE. Kali bi.—Indolent ulceration of the tonsils. Affections of the throat, eyes, skin, and periosteum. RUPIA.— Thuja. SARCOCELE. —Aur. IRITIS.—Merc., Kali hyd. GUMMATA.— Merc., Kalö hyd. OZACNA.—Aur., Kali bº., Kali chlor., Kali hyd. CONDYLOMATA.—A c. 77%t., Thuja, Merc., Ant. tart., Ac. hos. - p CARIES OF Bone.—Awr., Mez., Phos., Kali hyd., lºſer.c., Ac. fluor. - º ULCERATION OF THROAT.—Merc., Kali bº., Ac, nit., Iod., JCalò iod., Hydr., Ac. fluor. - - CHANCROID. SYNONYMI: Soft Chancre. DEFINITION.—A virulent, local, contagious ulcer, never giving rise to constitutional symptoms, its effects being limited to the vicinity of the sore, and the neighboring lym- phatic glands. It is never transmitted by inheritance. It is auto-inocu- lable. A person may have repeated attacks. The prognosis is always favorable. LESION.—A round or oval ulcer, surrounded by a faint, pink areola, with abrupt edges, sharply cut at right angles to surface, often slightly undermined, the bottom being irregular, Soft, and covered with pultaceous, dirty-yellow blS. . p IRIEMEDIES, Mercurius, Arsenicum, Acid mit., Kali bi., Hepar sulph., Phosphoric ac., Silica. - IOCAL.—Touch with strong Nitric acid. Before cauteriz- Žng, cleanse surrounding parts with Carbolic lotion. Do not cauterize unless the whole of diseased surface can be acted on. Chancres beneath phimosed prepuce, treat by frequent injections Carbolic lot?0m (1:40), using syringe with long nozzle. - - - When caustic not used, best application is Jodoform ; dust on powdered crystals, cover with dry lint, and use retaining dressings. Dressings of all kinds must be changed frequently, and opposing surfaces kept apart. Destroy old dressings; use no greasy applications. . PARAPHIMOSIS. If strangulation occur, effect reduction. In phºmosis, if swelling so great as to prevent the use of syringe, or if sloughing threaten, slit up the prepuce by double incision, CHANCROID—GONORRHCEA. 177 or remove altogether, and treat as phagedaena. Otherwise, hot local baths to reduce oºdema. PHAGEDAENA. Immerse the entire diseased part in a bath at 98°F., and maintain this heat for nine or ten hours per day. Use hip bath; continue for several days after sore puts on healthy appearance. Tiet the patient go to bed at night, dressing the sore with Iodoform. If disease not arrested, make bath continuous; full bath, in which patient can lie down, will accomplish this. If milder measures fail, cauterize. Check all haemorrhage at once; apply to bleeding point pledget of lint soaked in solution Persulphate of iron, retained by firm bandage. - GENERAL.—Rest; good food; good ventilation. In phagedaena, tonics and Cod-lºver oil. BUBO. To favor resolution, use pressure and dry heat. If sup- puration be found to be inevitable, promote with poultices; open by free incision across the line of Poupart's ligament, as soon as presence of pus is manifest, and treat same as local sore. Aspiration of no service. - GONORREIOEA. ACUTE STAGE. LEADING REMEDIES. - Gelsermium.–In recent cases. Discharge moderate; much irritation; considerable heat; little pain; smarting and redness at meatus. DOSE—One to two drops every three hours. - Has a striking effect on the acute stage of gomorrhoea, usually bringing relief in twenty-four to forty-eight hours. Fully ninety per cent. of cases report speedy relief.-Adams, Cannabis sat. tinct.—Smarting, burning, stinging, dur- ing micturition; constant urging; copious, thin discharge; prepuce swollen and painful; strangury, pains extending into Scrotum, with dragging in testicles. A characteristic indication for this remedy is priapism.—Adams. Cantharis, 2x.—When urinary symptoms indicate that inflammation is extending toward bladder; ardor wrºnae, cutting, Stinging palm during and after micturition. Particularly called for when blood occurs, either free or mixed with discharge —Adams. . Mercurius, 2x. — “When inflammatory process is accompanied by free exudation into submucous tissue and thickening of the urethral walls, producing great dimºnº- tºon ºn the size of the Stream of wrine, and chordee.”— Adams. - 12 178 KEY NOTES OF MEDICAL PRACTICE. Local.– Astringent and irritative injections are of doubtful utility. Observe strict cleanliness of the part. To absorb and remove discharge, keep a piece of lint over the meatus, retained by drawing the prepuce over it, or a piece of soft linen, with a hole in the center, drawn like a collar just back of the corona glandis, and the corners then brought forward, with the prepuce over it. Avoid use of warm and cumbersome dressings: tissue paper is best. Renew dressings frequently, and destroy old ones. Wear a light suspensory for the scrotum. - If, after well conducted course of treatment, a “drop or two” still appear, suspect incipient stricture, and use me- chanical dilatation. . DIET. —Avoid all greasy, fried, or highly Seasoned articles — pepper, vinegar, Salt, coffee, or tea. Salad dress- ings, asparagus, acid fruits, tomatoes, strawberries, pas- tries, and particularly all malt, Vinous, and spirituous liquors should be strictly prohibited. Ilet the diet be light; plain milk diet best. Drink large quantities of soft water. GENERAL.—Rest in recumbent posture will greatly pro- mote recovery. In any event, to as great an extent as possible, avoid physical exertion, and all sexual excitement. CHORDEE.-- Empty the rectum by enema before retiring. Sleep on hard mattress, with light bed-clothes; room cool and well ventilated. Whcn erection occurs, evacuate blad- der; stand on cold oil-cloth. Medicinal treatment as for original disease. External application of Camphor-ice along urethra, at night, has prevented chordee. INJECTIONS.-- Useful in but small number of cases. Hot mucilaginous infusions best — gum water, linseed water, with a little Hydrastis. Any injection which causes greater pain than very slight smalting will do more harm than good. In any case, must be employed very early—later, of I] O Úl SG2. . - RETENTION OF URINE.—Avoid passage of catheter ºf possible! Quiet mental anxiety; inject in perineum Morphia, % grain, and Atropia 1-120 grain; repeat in an hour; place patient in hot bath, submerged to the chim, until the flow of urine begins; if signs of syncope appear, remove him from bath, put a hot mush poultice over the hypogas- trium, and give an enema of hot water and soapsuds. All other means failing, aspirate the bladder. STAGE OF DECLINE. LEADING REVIEDIES. Mercurius iod. — Discharge free and mucoid; patches of induration found along urethra. Sepia. — Chronic mucoid discharges, without pain. Es- pecially gonorrhoea of females. GoNoRRHOEA–URETHRAL STRICTURE. 179 Hepar sulph.-Muco-purulent discharge in those who have had several attacks. Thuja.-Thin, whitish, painless discharge. Sub-acute and chronic cases, especially when there is inflammation of prostate. . - Sulphur.— Much thickening along urethra. Silica.--Cases of long standing, with slight, shreddy discharge. INJECTIONs.— May be used in this stage. Half a grain of Argentum nit., Zinc sulph., or Plumbum acet., to ounce of water. Powdered Hydrastis Ess. to 3.j. water, excellent in cases of long standing. Short-nosed, hard-rubber syringe holding 3ij. First clear the urethra by urination, or warm water. Insert the nozzle just within the meatus; compress the sides of the urethra with thumb and finger above the syringe tip; inject slowly. Retain the injection for a minute or two, manipu- lating the urethra. - If the discharge persist, pass slowly a full-sized, smooth, steel sound, at intervals of three or four days. GT,EET. Treat by slightly astringent injections, and remedies as indicated above. But a permanent cure demands treatment of the accompanying URETHRAL STRICTURE. Chronic urethral discharge always indicates stricture, and the latter must be treated. Pass an olive-pointed . bougie, not beyond the prostate, using no force. If the meatus be contracted, with keen-edged bistoury cut down- ward and backward in the median line, and insert a piece of oiled lint to prevent primary adhesion. Make gradual dila- tation at point of stricture with olive-pointed bougies up to No. 8, then steel sounds. Never use a steel Sound smaller than a No. 9. Leave bougie in situ only a few moments, and introduce larger sizes at intervals of two days, more or less, according to patient's urethral sensibility. Use no force. Make haste slowly. Gradual dilatation should be carried up to normal size of urethra, as ascertained by bulbous bougie, or urethrometer. Traumatic and resilient strictures, and those of the penile urethra, should be treated by over-distention and urethrotomy combined. - 180 KEY NOTES OF MEDICAL PRACTICE. EPIDIDYMITIS AND ORCHITIS. LEADING REMEDIES. Pulsatilla. —Sub-acute inflammation, the glands alone being affected; pain shooting down the back or into the thigh, and changing Suddenly. . Hamamelis.--Dull, heavy pain in testicle, at times ex- cruciating. Scrotum hot, congested, and Swollen; the skin tense, smooth, and Shining. Aconite.— Fever; hot, dry skin; full pulse; great Vascu- lar excitement. Belladonna. – Great sensitiveness of nervous system, with intolerance of pain, which is of neuralgic character. Clematis. – Orchitis following chronic urethritis. Arnica, Conium.–From contusion. - GENERAL WIFASTURES. Absolute rest in bed—do not let the patient rise even to relieve bladder or bowels; support the testicle so as not to drag on the cord; apply hot Hamamel's fomentations; after inflammation has subsided, strap with adhesive plaster so as to make pressure. Relief of tension of tunica Vagi- malis is promptly afforded by puncture, a straight, three- cornered surgical needle being passed through the Scrotum, and six or ten punctures being made in the envelope of the testis. - HYDROCELE. EEMEDIES. Iodine, Calcarea carb., Silica, Aurum, Pulsatilla, JRhododendron, Graphites, Kalö hyd. Operative Treatment. – In infants acupuncture, caus- ing the fluid to escape into areolar tissue of Scrotum, often CUll’OS. - Palliative Treatment.—For adults, evacuate the con- tents of the sac with aspirator or trocar. Method.—Make out the position of the testicle; grasp the tumor firmly in the left hand, with the testicle occupying the middle of the palm. Plunge the needle or the trocar obliquely upward and backward into the juncture of the middle and lower thirds of the hydrocele. Radical Cure.—Tap the hydrocele with a small trocar; empty the sac of all fluid and inject liquid Carbolic acid, twenty to thirty minims, manipulating the sac so as to bring the acid into contact with its entire surface, allowing the i. to remain. Confine the patient to room for forty-eight OUll’S. ... This method is followed by a radical cure in most cases, and is un- attended by fever or other complications.—Adams. - THE TEMPERAMENTS. 181 PART IV. MISOELLAN EA. THE SEVEN AGES. . Infancy—from birth to 7th—10th month; . Childhood — from 1st to 2nd dentition; Boyhood—from 2nd dentition to puberty; . Adolescence—from puberty to 20th – 25th year; . Early manhood — from 25th to 45th year; . Later manhood—from 45th to 60th year; . Old age — from 60th year onward. i THE TEMPERAMENTS. SANGUINIE TEMPERAMENT. The form is full and round, neither very gross nor very spare, and the muscles firm and elastic. The complexion is lorid and ruddy, from the rich capillary circulation. Arterial blood abounds, the veins being small, the circula- tion active, and the pulse full and quick. The bodily func- tions are quickly and easily performed. Mind and body are quickly stimulated into action, and there is great endur- &ll CG. - - - There is an intense animation and buoyancy of spirits, and in the mental sphere rapid thought, Vivid imagination, and quick perception. - - - Subjects of this temperament are prone to congestions, inflammations, and fevers, and all diseases are inclined to take on inflammatory action. REMIEDIES. Acomºte, Belladonna, Bryonia, Gelsemium, Veratrum ^y}r. NERVOUS TEMPERAMIENT. The habit is spare, the frame somewhat angular, the muscles spare, and not well defined. The skin is dark, dull, 182 IXIEY NOTES OF MEDICAL PRACTICE. earthy, or sallow, and hot and pungent to the touch. The cranium is large. The circulation is languid, with a pre- ponderance of the venous system; the pulse variable and easily excited. The face has the lineaments of energy, and movements are hasty and abrupt. The mental powers are large, and capable of persistent exercise. The affections are violent, and the sexual passions usually very strong. Sensations have an intensity far in excess of the exciting cause. - The individual is subject to neuralgia, nervous diseases, spasmodic affections, and mental disorders. REMEDIES. Atropia, Ignatia, Coffea, Valerian, Moschus, Phosphorus, 2ömcwm. - LYMPEIATIC. TEMPERAMENT. The body is heavy, inclined to corpulence, the flesh full but soft; the joints and hands large, and the feet broad and flat. Compleañom sallow or pasty; the hair light or reddish. The pulse is slow and easily compressed. The bodily func- tions are slow and languid. The chest and heart are in- adequate in bulk to the rest of the body, The mental processes are slow, though there is great firmness and constancy, and usually good judgment. These subjects are inclined to glandular enlargements, catarrhal affections, abscesses, and dropsies. There is slight power of resistance to acute diseases, with a tendency to take on the chronic form, especially of the strumous and asthenic kinds. . - REMEDIES. Arsenicum, Jodine, Calcarea, Hepar Sulph., Mercurius, Sepia, Silica, Sulphur. BILIOUS TEMPERAMENT. Habit spare; muscles hard-knit; tendons wiry; com- plexion swarthy, with a yellowish tinge; sharp features; dark and deep-set eyes. They are characterized by violence of reaction to irritation, particularly of the biliary appara- tus, with disturbances of the digestive functions, dark- colored urine, and constipation. The bilious derangement engenders melancholy, ill humor, and acrimony of temper. IREVIEDIES. Nua, vomica, Chamomilla, Bryonia, Sulphur, Podo- phyllön, Aloes. LEGAL MEDICINE. 183 LEGAL MEDICINE. Expert Testimony.—A physician is in law an expert as to all matters embraced within the range of his profes- sion. It is not necessary that he be at the time in actual practice. It is not necessary that he should have made the particular disease involved in any inquiry a specialty. . But if he has devoted himself exclusively to one branch, and has had no experience in that subject to which he is called to testify, his testimony is inadmissible. A practicing physi- cian, whose knowledge of the particular subject of inquiry (e.g., insanity) was derived from study alone, has been held competent to express an opinion as an expert. Medical books are not admissible in evidence. - An expert cannot be compelled to attend during the entire trial for the purpose of hearing all the testimony. The law is extremely conflicting as to whether profes- sional men can be compelled to testify as ea:perts without extra compensation. In England it is settled that addi- tional compensation is required. In the United States the question is open, with the weight of authority in favor of the English rule. - In the absence of any statutory provision to the contrary, it is well settled that a physician or surgeon may be com- pelled to disclose any communications made to him in pro- fessional confidence. This rule has been abrogated in several of the states by express statutes. Physicians and surgeons shall be incompetent to testify as to infor- mation obtained in a professional capacity from a patient.—Missouri. No person duly authorized to practice physic or surgery shall be allowed or compelled to disclose any information which he may have acquired in attending any patient in his professional character, and which information was necessary to enable him to prescribe for such nºt 'as a physician, or to do any act for him as a surgeon.—New Skill Demanded.—A physician's charge is more on ac- count of his skill and knowledge than of the time given to his patient's case. He is held to exercise ordinary care and skill, but is not held to produce any benefit to the patient. The only defense against a suit for physician’s service ren- dered on employment is, first, as to the unreasonableness of the charges, or, second, actual malpractice. But a phy- sician must adhere to the system and the custom of the branch of the profession he has avowed. Collections.—A physician has a right to demand and sue for reasonable charges for professional services rendered upon employment, either in advice or aid. Books of original entry only are received as evidence. A bill of items may be demanded by the debtor. - When a patient receives, without objection, the services of an assistant, or a student, he is bound to the principal 184 REY NOTES OF MEDICAL PRACTICE. for the same. But where partners both attend a patient, they must recover in the firm's name, A bill for services rendered to a servant must be collected from him, unless the master expressly agrees to pay for the same. A minor may be held responsible for medical aid rendered him. - - Either the husband or wife, or both jointly, may be held for services rendered to one of the family. A city must pay for services rendered by a physician called by a police officer, if the case is urgent, and the regular City Physi- cian and Surgeon is absent. - Good Will.—A physician may sell the “goodwill" of his practice, or his business, and may contract that he will not, within certain places and times, practice his profession; but an agreement not to practice his profession at all is unlawful and cannot be enforced, because it is against public policy. Jurors.-Practicing physicians are exempt from duty as jurors. Liability of Physician.-A physician is liable for any damage caused by malpractice. He is also liable for all acts of an assistant or student done in the regular course of business. - - Malpractice.—A physician or surgeon must bring to the performance of his duties as a professional man at least ordinary skill and knowledge, and must apply without mistake what is settled in his profession; and must have the knowledge of the best and leading authorities in his science, down to the time the act is performed, or he is liable for damages that may accrue from his practice. - LAw REGULATING THE PRACTICE of MEDICINE IN THE STATE OF ILLINOIS. Every person practicing medicine, if a graduate in medi- cine, shall present his diploma to the State Board of Health, for verification; if found to be genuine, the State Board of Health shall issue its certificate to that effect, and such diploma and such certificate shall be conclusive as to the right of the lawful holder of the same to practice medicine in this state. If not a graduate, the person practicing medi- cine in this state shall present himself before said Board and submit himself to such examinations as the said Board shall require, and if the examination be satisfactory to the examiners, the said Board shall issue its certificate in ac- cordance with the facts, and the lawful holder of such certificate shall be entitled to all the rights and privileges herein mentioned. Every person holding a certificate shall have it recorded in the office of the Clerk of the County in which he resides. INFANT DIET. 185 Any person removing to another county to practice shall record the certificate, in like manner, in the county to which he removes. . The State Board of Health may refuse certificates to individuals guilty of unprofessional or dishonorable conduct, and they may revoke certificates for like causes. - Any person shall be regarded as practicing medicine, within the meaning of this Act, who shall profess publicly to be a physician, and to prescribe for the sick, or who shall append to his name the letters “M.D.” INFANT DIET. In order to prepare cow's milk so as to adapt it to the wants of the infant organism, it must be diluted by the addition of a mucilaginous liquid, such as gum-Arabic water, barley water, gelatine, or oatmeal water, and some Bicar- bon/tte of Soda, sugar, and a little salt added, in about the following proportions: Fresh milk, - - - - - - - Hot water, - - - - - - - - 1 teacupful; Soda (bicarb.), - - - - - - - % teaspoonful; Sugar of milk, - - - - - - - 1. & 6 Salt, - - - - - - - - - - A little; Gelatine, - - - - - - - - - 1 tabléspoonful. First dissolve the soda, the sugar, the salt, and the gela- time in the hot water, and then add the milk. Make it fresh at each feeding. This is about the right proportion for a baby of four months; under that age de- crease the º of milk slightly; over that age, in- crease it. In place of the gelatine, oatmeal water, barley Water, or gum-Arabic water may also be used, substituting a cupful of either for the pure water which is used when gelatine is employed. The addition of some gelatinous fluid Seems to favor the digestion of the milk. Oatmeal Water.—Soak a teacupful of oatmeal in a pint of water, with a little salt added, over night. Strain thoroughly, through a napkin, next morning. - Barley Water.—Take a teacupful of pearl barley, and Soak it for half an hour in a little lukewarm water, pre- viously salted. Drain off the water, pour the barley into a pint of boiling water, and let it simmer one-half hour; when done, strain into a pitcher. . . . . Gum-Arabic Water. — Dissolve pure gum-Arabic in water, one part to ten, by bulk. For very young babes, use the gum-Arabic water, in the proportion above given; for older children, barley water if the bowels are loose, oatmeal water if there be constipation. A little gelatºne added to the mixture of milk and water may be substituted for any of the above. 1S6 KEY NOTES OF MEDICAL PRACTICE. DIET IN CHOLERA INFANTUM. Keep the child cool, let it have plenty of fresh air, i.ed let it have no food in which the process of fermentation has begun. Avoid Starchy foods. The milk and barley water, prepared as above, may be all- sufficient. Keep litmus paper on hand, and test the milk frequently; if it show any acidity, reject it. Albumin Water.— Gently stir the whites of two eggs into a half pint of cold water, and sweeten with a little Sugar of milk. This is the most simple food that it is possible to obtain, and may be resorted to when all others fail. Wine Whey.— Heat a pint of fresh milk to the boiling point; add slowly a wineglassful of sherry wine, and let it gently simmer until the curd forms. Strain the whey through a cloth, and sweeten. This is mourishing and stim- ulating. - DIET IN FEVERS. Give no solid food to a fever patient. Let all food be simple but nutritious. Give food at frequent intervals and in small quantities. Food for fever patients should be fluid in form, easy of digestion, and highly nutritious. Those who have been properly nourished make the best recoveries. In typhoid, and diseases in which the bowels have been affected, no solid food must be given until the stools are again consistent and fecal. Milk is the best food that can be given. So long as the patient can take it, none other need be sought for. Beef Tea, in the stage of depression, is useful as a stim- ulant. RECIPE.—Take one pound of fresh meat, cut very fine, soak in one-third of a quart of Gold water over night. In the morning remove the meat, saving the water in which it has soaked. Put the meat in two-thirds of a quart of water, and let it simmer for two hours, keeping the water up to its original level by replacing what is lost by evaporation. Now pour the beef broth into the cold liquor in which the meat was soaked, squeezing the meat as dry as possible. The meat which remains should be spread on a tin plate, and dried in an oven. When perfectly dry it can be easily reduced to a powder in a mortar. Mix this meat powder in the liquor, and you have all the elements of the meat in a fluid form. Salt to taste, and add twenty drops of JIurbatic acid and three grains of Pepsin. This is the Only preparation of beef tea which contains all the elements of the meat. RECTAL ALIMENTATION. 1S7 RULES FOR MAKING BEEF TEA.— Never let beef tea boil. Always begin with cold water. Cut the meat very fine, and remove all fat, gristle, and bones. The proper proportion is a pound to a pint. After making, carefully remove all traces of fat. To warm up beef tea, put it in a bowl, and set the bowl in a vessel of hot water. Egg Nog.— One egg; one glass of milk; one dessert- spoonful of brandy; one dessertspoonful of Sugar. Care- fully scald the milk, and let it afterward become cold. Beat the sugar and egg up together to a froth, put into a glass, add the brandy, and fill up with the milk. If wanted in a hurry, the milk may be used without Scalding. Mutton Broth.--Take a pound of fresh mutton, free from fat; cut into thin slices with a sharp knife; put into a suitable dish, salt, pour over it a quart of cold water, and let it sºmmer over a slow fire for an hour; then let it boº! for an hour longer. Strain off the broth, refusing the meat fiber. Season with salt. RECTAL ALIMENTATION. Preparatory to giving an enema, empty and wash the rectum by giving an injection of clean, warm water. Force the enema in slowly. Throw it as high up as possible. Inject at intervals of two hours. Inject no more than half a teacupful at a time. Let the enema have a temperature of about that of the body – 98° or 100° F. - Warm Milk, with a little salt in it, makes a simple and readily absorbed enema. Heat the milk to the proper tem perature, inject every two hours, and the patient is getting considerable nourishment. Beef Tea, made according to the recipe given, makes a very nutritious enema. The Pepsºn and Muratic acid are necessary to fit it for absorption. Cod-liver Oil.-Chop fine a half pound of beef pancreas; cover this with water and allow it to stand for an hour in a warm place. Strain through a cloth. Mix an ounce of this pancreas solution in a half ounce of Cod-liver oil, and use as an injection in those cases in which it is desired to supply the system with fat. NUTRIENT SUPPOSITORIES. Take a quantity of the whole beef tea, set the basin com- taining it in another vessel of hot water on the stove, and evaporate the water from the beef tea until it becomes of a 188 KEY NOTES OF MEDICAL PRACTICE. creamy consistence. Now add an equal quantity of Cacao butter, melt both together, pour into a dish, and allow the mixture to cool and solidify. With a warm knife cut into bits, and shape like a pigeon's egg. These nutrient supposi- tories, introduced into the rectum at frequent intervals, will afford nourishment to the system in the neatest and cleanest way in which artificial alimentation can be practiced. MILK DIET. Diabetes, Bright's disease, dyspepsia, and some other diseases, undergo great improvement on an exclusive milk diet. The following rules will aid in carrying out this treat- ment: Use fresh milk. The milk may be taken cold or warm, but it must not be boiled in the warming. The first day take from four to sta; pints. This would be from two to three glassfuls taken every two hours during the day. It, º better to divide the day into equal periods, and take frequent draughts—even though a glassful be taken every hour — than to take a large quantity on the stornach at once. The quantity of milk should be increased from day to day until five or six quarts are taken daily. This quantity, six quarts, need not be exceeded. In diabetes, mothºng else must be taken while the milk diet is used. If at the end of a week there is no improve- ment, the treatment may be abandoned. If the treatment be of benefit it will be denoted by a diminished amount of urine, less sugar, and improvement in the general health. It should be continued from three to six weeks after all sugar has disappeared from the urine. POULTICES. Cataplasms are local baths—they supply heat and moisture to a part, Soften the Cuticle, relax the skin, dilate the vessels, lessen tension, and relieve pain. Used in —Pneumonia, pleurisy, bronchitis, pericarditis, peritomitis, other internal inflammations, rheumatism, lumbago, and to mature abscesses. Rules.—Do not remove one poultice till next is ready to replace it. A poultice should be applied as hot as it can be borne. Change a poultice every two or three hours by day, every four hours at might. To make a poultice retain heat longer, cover with oil silk or cotton wool. Peritomitis re- quires a thin poultice; cover with cotton wool. In suppu- rations, do not let poultice be larger than the abscess it is intended to cover. POULTICES — MOIST FOMENTATIONS. 189 Linseed Meal.—Put sufficient hot water into a hot bowl, sprinkle the meal into the water, stirring vigorously until the required consistency is attained, and lastly stir in a small quantity of olive oil. Spread smoothly and evenly on a piece of muslin, and cover with a piece of cheese cloth. Oatmeal poultices may be prepared in a similar manner. Starch. —Add a little cold water to the starch, and blend the two into a pap; then add sufficient boiling water to bring it to the required consistence, and spread on cloth. This is meat, bland, and unirritating. Disinfecting Poultice.—Anoint the part with Car- bolic oil (1:10), and apply a pad of carded Oakum, Wrung out of hot water. - Fly Blister. — Spread a thin layer of Camtharides ce- Tate on a piece of brown paper, soft leather, or, preferably, a piece of adhesive plaster. Leave free margin around the salve. Moisten skin with vinegar, cover surface of plaster with tissue paper moistened with vinegar, apply and Secure by adhesive straps. From two to twelve hours minimum and maximum time to leave plaster on. Chloral Blister. —Take a piece of adhesive plaster of suitable size, moisten it, and sprinkle on Some powdered Chloral hydrate. Apply to the part where vesicant action is desired. Cantharidal Collodion.— Dissolve gun-cotton in an ethereal, Solution of Cantharides, Apply by means of a camel's hair pencil. This makes a very effectual and easily regulated vesicant. - Mustard Poultice.— Mix some linseed meal in a quan- tity of boiling water, to creamy consistence, then add same quantity of mustard as of meal used, stirring constantly. Spread on a cloth, cover with gauze, and apply. A mustard poultice should remain from ten minutes to half an hour, according to strength. Indicated when mild and rapid counter irritation is required. MOIST FOMIENTATIONS. Used to relax spasm, as intestimal, renal, and biliary colic. Directions.— Place a fold of flannel cloth in the middle of a towel, twist the ends of the towel, and dip the portion containing the flannel into boiling water, take out and *Urºng it until as much water as possible is pressed away. Take out the flammel and apply it to the painful part. Or, sprinkle a fold of flammel with warm water, and rum a very hot flatiron over it. . Compresses lose their heat rapidly, and must be frequently renewed. Turpentine Stupe.— If slight counter irritation be de- sired, sprinkle the fomentation with Turpentine. 19() REY NOTES OF MEDICAL PRACTICE. Poppy Formentation.— Sprinkle the fomentation with Laudamºm, if sedative action be desired. - DRY FOMENTATIONS When dry heat is required, put into a flannel or muslin bag, of suitable size, a quantity of hot Sand, hot salt, hot bram, or hot cornmeal. A hot plate, * in a cloth, answers well. A rubber bag filled with hot water is the most perfect. Put Acetate of Soda into a tin can, tightly closed, of suitable shape; set this in boiling water for thirty minutes; remove, wrap in flammel, and apply to painful part. It will give off heat for many hours. COLD APPLICATIONS. Ice-bags.-Put pounded ice, with a little water, into a bladder or rubber bag, filling it only half full. Use for re- frigeration and to contract the vessels and reduce conges- tion, especially in inflammation of the brain. Cold Cloth.- Cloths may be simply wrung out of cold water, or, put some salt and pounded ice into a tin basin, set this on a wet cloth, stir, and the cloth beneath may be quickly frozen to any required degree. Cold Drop.–Stand a vessel of cold water on a table higher than the patient's bed, put one end of a long strip of lamp-wick into the water, and lay the other across a cold cloth which is applied to the inflamed part. A continuous stream of gold water is thus conveyed to the part, and the water which passes from it must be caught in a basin on the other side. Cold Cap.–Stitch upon a mus- lin Cap, made to fit the head, a coil of rubber tubing, arranged spirally, with the two ends free. Wet the Cap, and put it on the head, then place one free end in a bucket of cold water, suspended at a height, and the other in another bucket on the floor. Let the water siphon from the upper to the lower bucket. When the upper one becomes empty, reverse their relative positions. This is a very efficient method of refrigerating the head in cere- - *- * bro-Spinal memingitis, and in “brain fever,” when it is desired to apply continuous cold. BATHS. 191 BATHS. TEMPERATURE OF BATHS. IRATH. WATER. WAPOIR, AIR, Cold, - - 33° to 65° F. - Cool, - - 65° to 75° Temperate, 75° to 85° Tepid, - - 85° to 92° - 90° to 100° - 96° to 106° Warm, - 92° to 98° - 100° to 115° - 106° to 120° Hot, - - 98° to 112° - 115° to 140° - 120° to 180° Bran Bath.-Boil four pounds of bran in one gallon of water, strain, and add the liquor to sufficient water for a bath. Use to allay irritability of skin, and to soften it in squamous diseases. Salt Bath. —Add rock-salt in the proportion of one pound to four gallons of water. Use as an invigorating bath, and to lessen susceptibility to cold. Alcohol Bath. – An ounce of Alcohol to the quart of water. Use for same purpose as Salt bath. Sulphur Bath. – Twenty grains of Sulphurel of potas- sium to a gallon of water. For skin diseases and rheuma- tism. s Mustard Bath. — Add a handful of mustard to the or- dinary hot bath, or a smaller quantity to a foot bath. Use when stimulating action is required. Cold Douche.—Lower patient's head, place rubber cloth under, and pour cold water from a pitcher over crown of head, the pitcher being slowly and gradually raised higher and higher, so that the water may fall with more force. Use in sumstroke, and intense cerebral congestion. Wet Pack. — Spread a comfort and several blankets on the bed, and over these a sheet wrung out of cold water. Bemove all of the patient’s clothing, lay him in middle of sheet, draw the edges of sheet over, and wrap the patient in it smugly, them draw over one side after another of blankets and comfort, and make all smug. Put cold Wet compress on forehead. Use to reduce temperature in typhoid, and to develop delayed eruption in scarlet, and other specific fevers. It develops the rash, greatly reduces the fever, quiets the pulse, renders the skin moist and comfortable, and abates the restlessness and Wandering.—Rånger". Blanket Bath. — A blanket is Wrung out of hot water, and wrapped around the patient. He is to be packed in three or four dry blankets, and allowed to rest quietly for thirty minutes. The surface of the body should then be 192 REY NOTES OF MEDICAL PRACTICE. well rubbed with warm towels and the patient made Com- fortable in bed. This is an easy means of inducing perspi- ration. Vapor Bath. –Improvised. Place patient, with clothing removed, in large, cane-seated chair, and Surround both completely with blankets, letting them extend to the floor, and be secured about patient’s neck. Under the chair place basin of hot water, with alcohol lamp beneath it; bring water to a boil, and patient will soon be brought into a state of perspiration which may be carried to any desired extent. Use in uraemia, Bright's disease, and whenever diaphoresis is required. Mercurial Bath. – Given as above, by adding a metal late, with lamp beneath, on which is put sixty to one-hun- red-and-eighty grains Bisulphuret of mercury. Used some- times in treatment of secondary syphilis. VENTILATION. To purify the atmosphere of a sick-room, nothing equals an abundance of pure, fresh air. To ventilate a room, and at same time avoid a draft, raise the lower sash, and shut it down upon a folded blanket placed beneath it, leaving an aperture of several inches be- tween lower edge of upper, and upper edge of lower sash. DISIN FECTANTS. No. 1. Copperas (Sulphate of Iron).- This is a cheap and good disinfectant for many purposes. It can be obtained at any drug store. In Warm water it will soon dissolve by stirring. When put into cold water let it stand all day, or over night. Use in about the following proportions: To a bucket of water, add - - 2 lbs. copperas. To a tub of water, add - - - 20 lbs. copperas. To a barrel of water, add - - - 40 lbs, copperas. This can be used for privy-vaults, water-closets, catch- basins, cesspools, etc. Pour into water-closet about a bucketful at a time, once or twice a day. TNo. 2, Chloride of Zinc.—This is one of the best of disin- fectants. It is superior to the Copperas Solution, but being more expensive, is not so available for use in large quanti- ties. Prepare in proportion of — Chloride of zinc, - - - - - - - - 1 pound. Water, - - - - - - - - - - - 2 gallons. DISINEECTANTS. - 193 Throw this into kitchen sinks, house drains, Cesspools, water-closets, and the like. Also use it in chamber-vessels, about the sick-room. - * -- No. 3. Bichloride of Mercury (Corrosive sublimate).-A so- lution consisting of one part of the Bºchloride of mercury to 1,000 parts of water is one of the most efficient disinfec- tants known. It can be used for water-closets, urinals, sinks, and cesspools, or for soaking clothing, towels, bed- ding, and other fabrics. Corrosive sublimate is a dangerous poison, and should be carefully handled. No. 4. Carbolic Acid.—This is an excellent disinfectant if used sufficiently strong, but a weak solution does little good. Two ounces Carbolic acid to one quart water — for night vessels, sinks, and water-closets. One pint Carbolic acid to five gallons water—for drains, sewers, and Cesspools. No. 5. Quicklime.—Unslacked lime may be used to throw about wet places, in damp cellars, under buildings or side- walks, or into privy-vaults. Outbuildings, stables, and sheds should be whitewashed. No. 6. Chloride of Lime.—This may be strewn about barns and out houses, and thrown into cesspools, drains, and Sewel’S. Do not use Chlorºde of lème about the house. Other dis- infectants, which are less offensive, are at the same time equally efficacious, and Some even of greater value. No. 7. Charcoal.—This is very useful to cover heaps of filth, pools, and wet places. Sometimes it is better not to disturb an old Cesspool; but, instead, cover it over with charcoal. Dry earth may be similarly used, and it is almost as good. No. 8. For Soiled Clothing.— Make a solution in the follow- ing manner: Sulphate of zinc, - - - - - - - - 1 pound. Carbolic acid, - - - - - - - - - 2 ounces. Water, - - - - - - - - - - - 4 gallons. Reep a tubful of this near the sick room, and into it place all Soiled bed-linen and clothing. 13 194 IXIEY NOTES OF MEDICAL PRACTICE. If clothing be subjected to a temperature of 212° F. (100° C.) for an hour, either by boiling or baking, it effectu- ally destroys all germs. After all, the best disinfectant is fire, and, if possible, everything which has been in contact with the sick had bet- ter be burned. No. 9. For Air of Sick-room.— Put into a saucer– Permanganate of potash, - - - - - % ounce. Oxalic acid, - - - - - - - - - - % ounce. Water, - - - - - - - - - - - 1 ounce. Mix well. In two hours add small quantity more of water. This will emit enough ozone, which is an active dis- infectant, for a large room. - Furmigation.—To fumigate a room, put some Sulphur (Brºmstone), broken into pieces, in a tin vessel, and set this on a brick which is placed in a tub having a little water in the bottom. Set the Sulphur afire, and hasten from the room, having all windows and doors tightly closed, and all cracks well stuffed, even to the keyhole. Keep the room closed for six hours, then open and air it. Eighteen ounces of Sulphur should be used for each space of one thousand cubic feet — a room ten feet square. sANITARY MEASURES To be observed during the prevalence of cholera, yellow fever, typhus, and other infectious diseases: Where absolute cleanliness eacists infectious diseases do ^ot prevail. This is the key to the entire subject of pro- phylaxis. Cholera is most destructive where human life is massed on low, undrained sites which have been long occupied. Those who live in clean, dry, airy, and well drained locali- ties have little to fear from its visits. But cities and towns must prosecute a rigorous system of scavenging, and the work must be thoroughly dome. Every spot where there is any organic matter liable to decay must be thoroughly cleansed. All deposits of garbage, débris, or filth of any kind, must be removed, and the places purified by the free use of disinfectants. The scavenger must clean alleys of the accumulations which they usually contain, and all places once cleaned must be kept clean. The garbage thus gathered should be removed to a great distance, and, if possible, burned. Cesspools and sinkholes must be drained till dry, disin- fected, and then filled up with dry earth, and kept dry. In towns each house owner should clean up the back i. so often the receptacle for garbage, gather it into a heap and burn it. - DISINFECTANTS. 195 In cities Sewers should be flushed again and again, and everything washed and cleansed that will bear it — courts yards, areas, passages, and pavements. - - In flushing sewers solutions of Chloride of lime or Per- 7manganate of potash should be used in large quantities. But once a place is cle/tº, and dry, let it remain so; moisture favors the decay of organic matter and the devel- opment of germs. - If stagnant pools have been left until the cholera has actually come, do not then disturb them, but throw in an abundance of disinfectants, and cover with dry earth or charcoal. All kitchen refuse and scraps should be burned. This can easily be done in stoves and ranges. Outhouses should be whitewashed, cleansed, and lime scattered in all corners and cracks. - Dâmp cellars should be drained and dried, ventilated, whitewashed, and have lime scattered about all dark corners. In houses the drain pipes, sewer pipes, and all plumbing must be put in perfect order, that there may be no leakage of sewage and no escape of gases. . Flush all water-closets daily by pouring down a bucket- ful of disinfectant solution. - In typhoid fever, cholera, and epidemic dysentery, the discharges should be burned. This can be accomplished by mixing the excretions with a sufficient quantity of charcoal or sawdust, and burning this in a brisk fire in a furnace or stove, which may be devoted to that purpose. DRINKING WATER. The germs of cholera, typhoid fever, and epidemic dysen- tery are conveyed by means of drinking-water more than by any other one agency. Hence, to avoid these diseases, use only water which is absolutely pure. - Use no well water which contains surface drainage. Do not take water from a pitcher or other large vessel standing in a close room. All drinking-water should be boiled and filtered. Do not simply warm it, but let it boil. . The flat taste of boiled water may be corrected by filling a large bottle half full of the water and shaking it violently, So as to mix it with air. Keep all drinking-water in glass or earthen vessels which have been well scalded. . 196 REY NOTES OF MIEDICAL Pit ACTICE. MICROSCOPICAL EXAMINATION OF THE TJRINE. GENERAL RULES. 1. Sediment in the urine has no significance unless deposited within twenty-four hours. 2. Albumºn in the urine does not indicate kidney disease unless accompanied by tube casts. The most fatal form of Bright's disease (contracted kidney) has little or no albu- min. 3. Every white crystal in urine, regardless of shape, is a phosphate (except the oxalate of lime, which has its own peculiar form), when the urine is alkaline. 4. Every yellow crystal is wric acid if the urine is acid, or a urate if the urine is alkalime. - 5. Mucous casts, pus, and epithelium signify disease of the bladder (cystitis), or of other parts of the urinary tract, as determined by the variety of epithelium. 6. The urine of females can often be differentiated from that of males, by finding in it the tessellated epithelium of the vagina. 7. Hyaline casts (narrow), blood, and epithelial casts, signify acute Catarrhal nephritis. Much albumin. 8. Broad hyaline casts, and epithelial, dark granular, and oil casts, signify chronic catarrhal mephritis. At first, much albumin; later, less. 9. Hyalime and pale granular casts and little or no albumin signify interstitial nephritis. 10. Broader casts are worse than marrow casts, as far as diagnosis is concerned, for the former signify a chronic disease. 11. The urine should be fresh for microscopical exam- ination, as the micrococci will change hyaline casts into granular casts, or devour them entirely, in a short time. 12. Trommer's test should never be trusted to alone, if the amount of Sugar is small. 13. The microscope gives better ideas of the exact con- dition of affairs in the examination of urine than the vari- ous chemical tests.--Dr. H. l'. Formad. MICRoscoPICAL APPEARANCES OF URINE, 197 ſ] () \ } §§: Pºſë,”W º żº Phosp; º º ots. Blo º º tº 198 IXEY NOTES OF MEDICAL PRACTICE. URINALYSIS. Albumin. Blood. Pus. Mucus, Bile. Sugar. Sugar. TUrea. TJric Acid. Phosphates. Chlorides. IIydrochloric Render urine sight'y acid—if not already so- by Acetic, or Nārāc acid; boil, and add one-tenth bulk Włºść aćd. Heat the urine, then add Caustic potash, and heat it again. Let urine stand till sedi- ment deposits; pour off super-natant fluid; add to remaining sediment equal volume Liguo?” potasSGe. Add to freshly voided urine some Acetic acid; if considerable turbidity ap- pear, add Hydroch’oric acid. - Place Small urine and a few drops of red “funning” Nºtric acid side by side on porcelain dish, and allow them to gradually intermingle. Add to urine a few drops solution Cupric Sulphate, them its own volume Jiquor potass(e, and boil. (Albu- |min must be absent.) Take two specimens; to one add a bit of yeast; set side by side for twenty-four hours in temperature of 75° to 80° F., then take specific gravity of each. Take equal parts urine and Nitric acid, mix in a | test-tube and set aside. urine Q. S., add acid, one- eighth part;, set aside for twenty-four hours, Take Boil the urine; if there is a cloudy deposit, add | one-tenth part Nºt?"ic acid. . Slightly acidulate urine with Nitric acid, and add few drops solution Nitrate deposit on quantity | A white, cloudy boiling, which remains after addition of the acid. = Albumán. A dir/y, yellowish- red sediment, blood- Ted color by trans- milted light=13lood, Mix well, and a viscid, gel a ti no us ºnass, which, pours like white of egg= | I??!.S. If turbidity dis- appear, the urine becoming clear on addition of the HCl. = Mulcus. A play of colors— green, blue, Violet, red, and yellow or brown = Bâle. A precipitate of brick-dust-like sedi- ment= Sugar. If specimen which contained the yeast has lower sp. gr. than other=Sugar, Crystals of Nitrate of silver. of wrea — visible to naked eye—indicate excess of Üréa. A precipitate of square crystals= Užic &cid. - If the urine clear& wp on addition of the acid=A’hosphates. Clumpy, white pre- Cipitate= biloriaé. eacpectation of sickness, for the adult male. sickness increases with each year of life. : EXPECTATION OF SICKNESS. 199 ExPECTATION OF SICKNESS. The following table gives the expectation of life and the The amount of The young man of twenty-one is ill one-half week a year, while the man of sixty is ill two weeks and three-quarters on the average.— Dr. Cl. T. Campbell (Pop. Sci. Mom.). Expectation Expectation Expectation of sickness Expectation of sickness Age. Of life — for Age. of life — for years and that year— years and that year — decimals | Weeks and decimals. | Weeks and decimals. decimals. 21. 41.5 .450 41. . . . 27.4 .763 22. 40.8 .455 42. . . . 26.7 .803 23. 40.2 .460 43. . 26.0 .843 24. 39.5 .465 44. . 25.3 .885 25. 38.8 .470 45 . 24.5 .930 26, . 38.1 .476 46. . 23.8 .980 27, . 37.4 .483 47, . 23.1 1.035 28, . 36.6 .491 48. . 22.4 1.095 29 . . 36.0 .499 49. . 21.6 1,166 30. . 35.3 .509 50. . 20.9 1.230 31 . 34.6 .520 51. . 20.2 1.30S 32, . 33.9 ,532 52. . 19.5 1.396 33. . 33.2 .545 53. . 18.8 1.494 34 . 32.5 . 560 54. . 18.1 1.604 35 . . 31.8 .578 55, . 17.4 1.730 36. . 31.1 .599 56. . 16.7 1.875 37. . 30.3 ,624 57 . . 16.0 2.040 38. . 29.6 .653 58. . 15.4 2.230 39 . 28.9 .686 59, . 14.7 2.450 40. 28.2 .723 60. . 14.1 2,700 VITAL CAPACITY. Definition.—The capacity of the lungs, in cubic inches of air, as measured by the spirometer. The vital capacity varies according to Sea, height, weight, age, and disease. Sex. —The vital capacity of man exceeds that of woman, of same height, by about thirty-eight inches. Height.—There is an increase of eight cubic inches in vital capacity for every inch in height between five feet and six feet. Weight.—Excess in body weight is associated with diminished capacity in the proportion of about one cubic inch per pound excess. - 200 KEY NOTES OF MEDICAL PRACTICE. Age.—From thirty to sixty years the vital capacity decreases nearly one and one-half cubic inches per year. Disease.—In lung diseases the vital capacity is always diminished, and bears a certain relation to the extent of the lesion. . TABLE GIVING VITAL CAPACITY OF MALES AND FEMALES, AT DIFFERENT HEIGHTS. FEET, INCHES IM. F. FEET. INCHES. IM. F. 4 - - - 7 - - - - 126 - - - 88 5 - - - 4 - - - - 198 - - - 160 4 - - - 8 - - - - 134 - - - 96 5 - - - 5 - - - - 206 - - - 168 4 - - - 9 - - - - 142 - - - 104 5 - - - 6 - - - - 214 - - - 176 4 - - - 10 - - - - 150 - - - Ił2 5 - - - 7 - - - - 222 - - - 184 4 - - - 11 - - - - 158 - - - 120 5 - - - 8 - - - - 230 - - - 192 5 - - - 0 - - - - 166 - - - 128 5 - - - 9 - - - - 238 - - - 200 5 - - - 1 - - - - 174 - - - 136 5 - - - 10 - - - - 246 - - - 208 5 - - - 2 - - - - 182 - - - 144 5 - - - 11 - - - - 254 - - - 216 5 - - - 3 - - - - 190 - - - 152 6 - - - 0 - - - - 262 - - - 224 Of twelve phthisical patients examined, those who had Zost over three-tenths of their vital capacity, only three lived longer than four months, as shown by the following table: PATIENT. LosT. SURVIVED, PATIENT. LOST. SURVIVED. No. 1 - - - - - 4-10 - - - - - 12 ds. No. 7 - - - - 4-10 - - - - 4 ms. ** 2 - - - - - 5-10 - - - - - 8 ms. ** 8 - - - - 3-10 - - - - 8 °" ** 3 - - - - - 4-10 - - - - - 2 “ * 9 - - - - 3-10 - - - - 4 “ ** 4 - - - - - 2-10 - - - - - 6 “ ** 10 - - - - 3-10 - - - - 3 ** ** 5 - - - - - 4-10 - - - - - 2 whºs ** 11 - - - - 3-10 - - - - 2. “ ** 6 - - - - - 6-10 - - - - - 2 “ ** 12 - - - - 3-10 - - - - 3 “ Phthisis.--To examine sputum for elastic fibers, mix it with soda solution (B. Liquor Soda, 3j., Agua, 3ij. M.) and boil five minutes. Then dilute with equal quantity distilled water, and pour into a flat porcelain vessel. The particles suspended in the water may be taken out and examined under a microscope. The fibers are brown, slightly reticu- lated, and a fraction of a millimeter in length. ARRANGEMENT OF THE TEETH. g; ; ; ; ; § 5 3 5 # '3. B '3 × 5 . § 3 ; Ś # Upper Jaw 2 1 4 1 2=10. Temporary Teeth, - - - - º - Lower Jaw 2, 1 4 1 2–10 o, ad s: , g; .. 3 & ă ă ă ă ă ă ă t ă ă ă ă ă ă ă - = @ $ 5 § 3 ; (Upper Jaw 3 2 1 4 1 2 3=16 Permanent Teeth, . - 32 | Lower Jaw 3, 2 1 4 1 2 3–16 ) ARRANGEMENT OF THE TEETH. 201 PERIODS OF ERUPTION OF THE TEETH. - TEMPORARY TEETH. . 6th or 7th month, two middle incisors. 9th “ two lateral incisors. 12th “ first molars. 18th “ canines. 24th “ two last molars. PERMANENT TEETH. 6th or 7th year, the four anterior or first molars. 7th “ two middle incisors. 8th “ two lateral incisors. 9th “ first bicuspids. 10th “ second bicuspids. 11th to 12th ‘‘ canines. 12th to 14th “ second molars. 17th to 21st “ last molars or “wisdom teeth.” Early closing of the fontanelles indicates early dentition, and vºce versa. - The teeth of rachitic children are about one month late. The “wisdom teeth” are the last to come and the first to go. Children have been born with teeth (New York Medical Journal, Vol. xxii, p. 444). Richard III is said to have been born with teeth. Cases are recorded where adults never cut teeth (Boston Medical Journal, March 6th, 1879, p. 183). A man said to be over one hundred years old, cut a complete front set of teeth (German “Ephemerides,” dec. ij. ann. 3, p. 57). Complete third sets have been cut. TEMPERATURE. 1° Centigrade = 1.8° Fahrenheit. Rule.--To convert Centigrade into Fahrenheit, multiply by 1.8 and add 32. Example.—37°C. × 1.8-i-32 = 98.6°F. Rule.—To convert Fahrenheit into Centigrade, deduct 32 and divide by 1.8. - Example.— 104°F.— 32 + 1.8 = 40°C. EQUIVALENTS. - F. C. |F. C. F. C. 97.0°– 36.1° 100° = 37.7° 104° = 40.0° 98.0°– 36.6° 101° – 38.3° 105° = 40.5° 98.6° = 37.0° 102° = 38.8° 106° – 41.1° 99.0° = 37.2° 103°– 39.4° 107° = 41.6° 202 KEY NOTES OF MEDICAL PRACTICE. An increase of one degree Fahr. above 98° corresponds with an increase of ten beats of the pulse per minute. If, in the first week of a supposed case of typhoid, the temperature fall to normal, for however short a space of time, it is not typhoid. . - Average temperature in health, 98.6° F. (37°C.). In rec- tum and vagina it is 0.9° to 1.8° F. higher. The daily range rarely exceeds 1.8° F. (1°C.) above or below the average. The axillary temperature may fall to 97°F. without col- lapse, or rise to 150°F. without fever. . In an instance of injury to the spine after a fall, reported by Mr. Teale to the Clinical Society (London Lancet, March, 1875), the young lady lived, though the temperature reached above 122°, and ranged for days between 112° and 114°F.—Da Costa. . HYPODERMIC MEDICATION. Select for injection, flexor side of arm, over biceps muscle, or abdomen, near umbilicus. Pinch up fold of in- tegument between thumb and forefinger, insert point of needle well beneath integument, inject slowly, withdraw Carefully. As a rule, not more than one-half usual dose, as given by the mouth, should be injected. TABLE OF DOSES. Muriate of Morphine, - - - - - - - gr. }6 to 3% Sulphate of Morphine, - - - - - - - - gr. 3% to 3% Sulphate of Atropine, - - - - - - - - gr. Tº to ºn Strychnine, - - - - - - - - - - - gr. ºn to gº Sulphate of Soda, - - - - - - - - - grs. 2 Sulphate of Quinine, - - - - - - - - grs. 2 to 4 Squibb's liquor of Opium, - - - - - - gtt. 5 to 40 Magendie's solution, - - - - - - - - gtt. 3 to 20 Tincture of Hyoscyamus, - - - - - - - gtt. 10 to 20 Tincture Cannabis, - - - - - - - - - gtt. 10 to 20 Ergot, Fl. Ext., - - - - - - - - - - gtt. 15 to 30 ATOMIZED FLUIDS FOR INHALATION. The following drugs may be used in the form of spray. The dose mentioned is to be added to one ounce of water: Acidum Carbolicum, - * * * - grs. 1 to 2 Acidum Sulphurosum, – fl. drs. 2 to 8 Acidum Tannicum, - - grs. 3 to 12 grs. 3 to 20 min. 5 to 20 grs. 1 to 3 grs. 5 to 20 grS. # to 1 grs. 5 to 10 Alumen Exsiccatum, - Aqua Laurocerasi, - Argenti Nitras, - - Borax, - - - - - Extractum Belladonnaº, - Extractum Conii, - - - AToMIZED FLUIDS FOR INHALATION. 203 Bxtractum Cannabis Indicae, - - - - - - gr. 4 to 1 Extractum Opii, - - - - - - - - - - gr. # to 2 Ferri Ammonio-Sulphas, - - - - - - - grs, 3 to 6 Hydrargyri Perchloridum, - - - - - - - gr. ºr to # Liquor Arsenicalis, - - - - - - - - - , min. 3 to 8 Liquor Calcis Saccharatus, - - - - - - - fl. drs. 1 to 4 Oleum Terebinthinae, - - - - - - - - , min. 1 to 5 Potassae Chloras, - - - - - - - - - - grs. 5 to 10 Potassae Permanganas, - - - - - - - - grs. 2 to 4 Potassii Bromidum, - - - - - - - - - grs. 2 to 10 Potassii Iodidum, - - - - - - - - - - grs. 2 to 10 Sodii Chloridum, - - - - - - - - - - grs. 5 to 40 Tinctura Ferri Perchloridi, - - - - - - min. 5 to 30 Tinctura. Iodi, - - - - - - - - - - - min. 1 to 15 Tinctura Opii, - - - - - - - - - - - min. 3 to 20 Zinci Sulphas, - - - - - - - - - - - grs. 3 to 15 Test for Chloroform.— When equal parts of Purified Chloroform and colorless, concentrated Sulphuric acid are shaken together in a glass-stoppered vial, there should be no color imparted to either liquid, or but a faint tinge of color imparted to the acid after twelve hours’ standing; neither should there be any sensible heat developed at the time of mixing. - Chloroform, as it evaporates from bibulous paper, should give but little foreign odor, and the paper should be left odorless after evaporation. Chloroform should not be used for inhalation without having been subjected to these tests. Iodoform.—To destroy the odor of, add three grains of Cwmarin to a drachm of Iodoform. Mixing Iodoform with Peppermint oil also masks its odor. . - Rubini’s Camphor.—Equal parts by weight of Cam- phor and spirits of wine, 60 degrees over proof. The spirits will dissolve and hold in solution its own weight of Camphor. Catgut.—To prepare chromicised catgut:—One part of Chromic acid is first added to five of water. One part of the solution thus made is then mixed with five of Glycerºne. Steep the gut in this for a week, and it will be capable of re- sisting the action of the tissues for a fortnight. Leeches may be kept for a long time in a jar of water to which has been added a very small quantity of a one-third solution of Salicylic acid. 204. KEY NOTES OF MEDICAL PRACTICE. Ice.— To keep in sick-room, tie a piece of flannel loosely over the mouth of the bowl, put the pounded ice in the nest formed by the depression as the cloth hangs down in the bowl, and cover with another piece of same material. In this way it will last throughout a warm night. Break bits off, a s wanted, with a pin. HARDENING BANDAGES. Starch Paste.—Starch is stirred in cold water to a uni- form, cream-like consistence, and then, constantly stirring, boiling water added to produce a clear, thickish mucilage. Starch Bandages are made by drawing through this paste ordinary roller bandages, of strips of muslim. Starch Splints.-Draw strips of pasteboard once quickly through hot water, then thickly smear both sides with the paste. APPLICATION.— Pad recesses about joints with cotton- wool, apply moist flannel roller, lay starch splints over this, and then bandage with starch roller. Envelop whole with dry roller bandage. Plaster of Paris.-Mix in porcelain dish, constantly stirring, pouring on sufficient water to make paste consist- ence of thick cream. It stiffens in five to ten minutes. To delay setting, add more water, or powdered borax; to hasten, use hot water, or add common Salt. APPLICATION.—Cover limb with dry roller bandage. then apply plaster bandage over this. WEIGHTS AND MEASURES. To learn to write prescriptions, in terms of Grammes, is really a very easy matter indeed, it being only necessary to bear in mind the following approacimate - EQUIVALENTS: 1 Grain (gr.) equals .06 Gramme (Gm.); 1 Drachm (3) equals 4. Grammes (Gm.); 1 Ounce (3) equals 30. Grammes (Gm.); hence, To convert Grains (or M.) into Grammes, multiply by .06; To convert Drachms (or f3) into Grammes, multiply by 4; To convert Ounces (or f3) into Grammes, multiply by 30.* * More accurately, .065 (.06); 3.9 (4); 31.1 (30). SIGNS OF DEATH. 205 IN. B.— Use an upright line in the decimal place. IEXAMIPLES. Iodoform Powder. Gm. B. Thymol, - - - - (m j) - - - - - || 06 Iodoform, - - - (grs. xxx.) - - - - 1 || 80 Calamine, - - - - (3) - - - - - 4 Starch, - - - - , (3.j) - - - - 30 Mix. - - Bromidia. B. Ext. Cannabis Ind., Gm. Ext. Hyosciami, - ad (grs. iij.) - - 18. Brom. Potass., - - - - - - - - - Chloral Hyd., - - aa (3v.j) - - - 24 Syrup simpl., - - - (3.j) - - - 30 Aqua pura, - - - - (3ij) - - - 60 Mix. SIGNS OF DEATH. 1. The entire and continuous cessation of the heart’s action. This must be tested by a practiced ear, using the stethoscope. Or, tie a ligature tightly about a finger; the part beyond the constriction will, if there be circulation, become bluish-red, while, where the ligature is applied, there will appear a narrow white band. If, during life, a little Ammonia solution be injected subcutaneously, a port- wine congestion is set up in the surrounding parts; no such * results when the operation is performed on a dead body. . - 2. The entire and continuous cessation of respºration. Test by the surface of a cold mirror held over the mouth; if moisture condense, breathing has not ceased. Hold a light feather over the lips, to see if there be a current of air pass- ing. , Set a glass of water on the chest — motion, if present, will be indicated by the images of surrounding objects re- flected from the surface of the water. - Six hours after cessation of signs of life, if the muscles do not respond to a strong electrical current, life is cer- tainly eactinct. - ARTIFICIAL RESPIRATION. To be resorted to in all cases of suspended animation if the respirations fall below ten to the mºnwie. Remove all clothing from chest and arms. Clear mouth of mucus. Patient on back, with small, firm cushion, or roll of clothing, under shoulders. Pull tongue forward and Secure it by string tied over tongue and under chin. Stand or kneel behind and at head of patient. Grasp the arms just above the elbows, and draw them gently and 206 KIEY NOTES OF MEDICAL PRACTICE. steadily outward, upward, and backward, till they meet above the head, keeping them in that position for two seconds. Then flex the arms at the elbows and return them slowly to the sides of the chest, and press the arms firmly against the chest, holding them there for two seconds. Repeat this º at the rate of fifteen or eighteen times a minute. hen spontaneous respiration has become reëstablisned, cease further effort, and proceed to induce circulation and warmth. - In changing operators do not miss a single movement. Occasionally blow a little of the vapor of Ammonia, or a little snuff, into mostrils. Persevere in this treatment for hours. After breathing has been restored, promote warmth by rubbing limbs upward, with firm, grasping pressure, and energy, using flannels, handkerchiefs, etc. Continue the friction under the blankets, or over dry clothing. Promote warmth by the application of hot bottles, hot bricks, blad- ders of warm water, etc., to the pit of the stomach, armpits, between the thighs, to the soles of the feet. Provide at all times for a free supply of fresh air. As soon as the patient can swallow give hot water, by the teaspoonful, and follow it by wine, diluted brandy, or coffee. Put him in a warm bed, and encourage a disposition to sleep. TRANSFUSION. To support a patient until transfusion can be performed— keep the head low; raise the limbs; make friction from the distal ends toward the body, and then apply Snug bandages about the limbs up to the body. Gently, but firmly, kneading TRANSFUSION. 20% the abdomen with the hands (if no wounded or diseased Con- dition of the part prohibit) will drive the blood to the heart. The object to be attained is to fill the blood-vessels, and get up vascular tension, so that the heart will have something to contract upon. For this purpose use the Solution of Schwartz. B. Distilled water, 100° F., - 2 pints. Common salt, - - - - - 1% drachms. Liquor soda-, - - - - - 20 drops. Mix. Select median basilic vein at elbow, or internal Saphenous, in front of internal malleolus. The collapsed vein is some- times hard to find — cut down upon it, expose it freely, and pass two ligatures under it. With one ligature, tie the vein at the exposed portion which is nearest the hand or foot; push the other ligature to the other end of the wound. Open the vein by raising the upper wall with a fine pair of toothed forceps, beneath which an oblique slit is to be made with Scissors, so as to make a small, flap-like opening. Raise the flap, and pass in the bulbous point of a Canule (glass, vulcanite, or silver), directed toward the center of circulation. Tie this in the vein with the second ligature. Have ready a glass funnel, to which is attached a foot of rubber tubing, with the canule at the other end. Have the tube guarded by a clip. Pour the Solution into the funnel; open the clip, and let the Solution start from the mouth of the canule, when the clip must be shut, and the point immediately intro- duced into the vein. Now open the clip, raise the funnel and the patient’s arm, and the Solution will be forced into the vein by hydro- static pressure. . Admit mo air. A few small bub- bles of air do no harm—the quan- tity to cause death must be consider- able. Inject no clots or foreign articles, which may act as embol. Ceep the Solution in a clean, warm, glass vessel. Inject slowly. Quantity — a half- pint to a pint. If signs of dyspnoea appear, stop the injec- tion by lowering the funnel, and wait for it to subside. During process keep Solution warm by wrapping funnel with hot flannels. As soon as the funnel is nearly empty, withdraw the canule from the vein, apply a compress, and treat as simple wound. 208 REY NOTES OF MEDICAL PRACTICE. POISONING. EMIETICS. Apomorphia.-Solution in water, 1:50; inject five to ten drops hypodermically. This is the most prompt and efficient emetic known. - Ipecacuanha.-Powdered, thirty grains in water. Sulphate of Zinc.—Thirty grains in water; repeat if necessary. Prompt and safe. Sulphate of Copper.— Five to ten grains dissolved in Water. - Mustard.— A tablespoonful in a half pint of warm Water. Common Salt.— Two tablespoonfuls in a half pint of tepid water. ANTIDOTES. For Opium.—Atropia Sulph., one-fortieth grain, or Tr. Belladonna, fifteen drops, repeated in fifteen minutes if necessary. Strong coffee, ad lib. For Arsenic.—Dialyzed iron, ounce doses frequently repeated. Hydrated peroaxide of iron, give ad lib. Iron TuSt. * For Strychnine. — Chloral, thirty grains, repeated if necessary; Bromwide of potasSººn, 3.SS. ; Anºmal charcoal, ad lib.; Tannic acid, ad lib.; Chloroform ; Ether; Nitrite of amyl, by inhalation. Ror Acids.-Lime water, ad lºb. chalk and water; Magnesia, mixed in water; Ammonia and water, 3.j to Żviij. ; ashes; plaster from the wall; tooth powder, in water; soap and water. For Alkalies.—Vinegar, freely; Acetic acid and water; lemon juice; Mu'iatic acid, freely diluted with water; any dilute acid. - Por Narcotics.-Coffee, Strong, given freely; Nitrite of amyl by inhalation; Ammonia ; galvanism; stimulants. Multiple Antidote.—B. Saturated solution Sulphate of iron, 3ijss; water, 3xx; Calcºned magnesia, 3ij; Animal charcoal, 3.j. . - Keep Iron solution separately, and the Magnesia and Charcoal mixed in a bottle of water. When required for use, pour all into bottle together, and shake. Give ad lib., a wineglassful at a time. - This is a perfect antidote to Arsenic, Zinc, and Digitalis; it delays the action of Salts of copper, Morphine, and Strychnine, and slightly influences Salis of mercury. Stimulants.--Wine, whiskey, brandy, Ammonia, tea, coffee, Ether. - - Instruments.--Stomach pump; hypodermic syringe; soft-rubber catheter; enema Syringe. - - POISONING: * - - 209 GENERAL DIRECTIONS. Emetic.— Give that emetic which can be most speedily obtained. If it be a corrosive poison, give copious draughts of demulcent drinks, followed by an emetic, and the appro- priate antidote. If the emergency be great, and no emetic at hand, give copious draughts of tepid water, even though it be dirty or greasy; then run the finger down the throat, to excite vomiting. The action of an emetic is facilitated if large quantities of fluid be swallowed. - Depression.— If present, must be combated by Słºmiſ- lants, warm application to the extremities, friction, galvan- ism, and, if the respirations fall below ten per minute, artificial respiration must be employed. Catheterize blad- der in prolonged cases. - Battery. —One pole at the side of the neck, the other over pit of stomach, or muscles of the chest. Or, touch the two poles to different attachments of the muscles of the chest, using Strong current, sufficient to excite pain, and produce efforts at crying. * - Flagellation.— In poisoning with marcotics, to combat the depression, and keep patient from sinking into fatal stupor, slap the skin with wet towels, spat the skin sharply, rub the soles of the feet with a stiff hair brush ; make every effort to rouse him. Walking the patient only adds eachaus- tion to stupor — better lay him on a lounge and use flagellation. Douches.—To aid in rowsing when there is stupor and depression, dash cold and warm water alternately, upon the head and chest. In apparently hopeless cases, two or three Sharp blows on the chest, delivered in quick succession, will sometimes restore the heart’s action. . . . Stimulation. —Alcoholic stimulants may be used if the poison is not a narcotic. Coffee may be employed as a stimulant in Belladonna, Opium, and other marcotic poison- ing; give an enema of a pint of hot, strong coffee. Am- ºn 07Wa may be given by inhalation, or by injection into veins. Strong tea is an excellent stimulant, and it also antidotes many poisons; give by the stomach, if possible. Whiffs of Ether, by inhalation, will stimulate the heart’s action. - - Demulcerts. –In cases of poisoning by corrosive sub- stances, give, after the administration of the antidote and emetic, large quantities of mucilaginous drinks; preferably white of egg and water. Demulcent Drinks. – Milk; white of an egg and . water; oil; linseed tea; gruel; flour and water; boiled sº Give in large quantities. - 210 ECIEY NOTES OF MEDICAL PRACTICE. KIND OF POIson. TREATMENT. ſ Provoke repeated vomiting; - Give demulcent drinks; Unknown. Multiple antidote ; Stimulate, if necessary. e ſ Provoke repeated vomiting; #. in © | Give strong coffee, etc.; #. { Inject Belladonna, chiorai. ' - Jēouse by flagellation ; g Artificial respiration. ( Provoke repeated vomiting; Arsenic — Give dialyzed Iron, etc.; Paris Green, { Give dose Castor oil; Scheele's Green. | Secure rest, - U Stimulate, if necessary. ſ Provoke vomiting once or twice; Strychnine, | Give purgatºve ; Picrotoxine. Give Chloral, etc.; • Secure absolute quiet. Acids— Sulphuric, Give an alkali ; JVitric, Provoke vomiting ; Muratic, - Demulcemi drinks; Ovalic, Stimulate, if necessary. Carbolic. U - Alkalies — ) ſcs; * * * * º W 0 & l, (, ; W 11) CO 8,1'). Ammonia, | º e ºn acid ( inegar) *Y. } Provoke vomiting; Soda, Y | 21 - . . . . . . .- D Demºlcemi drinks; Potash, | Stimulate, if necessary Lye, l s • ſ Provoke repeated vomiting; & © Vo Sù” utſ teſt **ool \r . Corrosive Sublimate | º e sh ºnly tºº, §º. & Tartar Emetic. ſ 3ye raw eggs and ºut, Give dose Castor oil, Stimulate, if necessary. ſ Provoke vomiting ; - | Sulphate of copper, Sol. gr.S. iij, Phosphorus. - every 5 ms., till emesis; | Epsom Salts, 3ss. ; U No oils or fats. Nitrate of Silver. ) ſ Strong solution salt and water, . J y : $ - g - - & wery freely t Lunar Cawstºc. t J 3 tº 8 e ( ) ) rovoke repeated vomiting ^. POISONING. 211 1&IND OF POISON, Sugar of Lead. Aconite. Digitalis. Belladonna, Stramonium, Hermlock, Toadstools, Tobacco. J Chloroform, | Carbonic Acid Gas. Y Alcohol. Decayed Meats ) and Vegetables. ſ Glass. TREATIMENT, Give Epsom Salls repeatedly; Provoke repeated vomiting; Give demulcent drinks; Give dose Castor oil. Provoke vomiting ; Stimulants, freely; Digitalis tinct. gtt. XX, hypo- derm. ; mustard over heart; Artificial respºration. Provoke vomiting ; Give strong tea ; Give stimulants; Jºecumbent posture. ſ|| Provoke vomiting ; Stimulants, freely; Hot, strong coffee : Opium, tinct., gtt. iij-V, or in Ol'C : Cold to head, galvanism, ſlag– ellation; Artificial respiration. Abundance of f, esh (tir, Pull tongue forward, clear the mouth; Loosen clothing, — head low ; Alternate cold and warm \ douche; Inhalations Amyl ºvifrite —-Am- 7monvča º ARTIFUCIAL RESPIRATION – Bat- tery. Stomach pump, or emetic ; Ammonia, and Water; Battery and flagellations; Cold douche to head : U Artificial respiration. Provoke vomiting ; Give purgative : Powdered charcoal, freely. If particles of glass have been swallowed, let the patient eat large quantities of bread crumbs, to envelop it — then give emetic. Do not let it pass into the bowels. | INDEx. ABDOMINAL typhus, 5. Abortion, 104. Abscess, 156. Acne, 87. Acupressure, 163. - Adherent placenta, 114. After-pains, 108. Agalactia, 120. Ague, 19. “ pernicious, 22. Albumin in urine, 198. {. water, 186. Alcohol bath, 191. Alcoholism, 75. Alopecia, 87. Amenorrhoea, 125. Amputations, 147. - Amputation at ankle joint, 150. * { at hip joint, 149. { % at shoulder joint, 148. ( (. of arm, 148. { { of ſingers, 149, { { of foot, 150. { { of leg, 150. of thigh, 150. of toes, 151. Amyloid kidney, 67. Anaesthesia, local, 166. Anaesthetics, 166. Amal fissure, 170. Angina pectoris, 43. Amtidotes, 208. - Amtiseptic surgery, 154. Apoplexy, 74. Apomorphia, 208. Army splint, 131. Artificial respiration, 205. Ascaris lumbricoides, 60. Asiatic cholera, 98. Aspiration, 169. Asphyxia of new-born, 113. Asthma, 33. - Atomized fluids, 202. BANDAGES, hardoming, 204. Barber's itch, 87. Barley water, 185. Bathing the patient, 8. Baths, 191. Bath, alcohol, 191. “ blanket, 191. {{ bran, 191. . . “ mercurial, 192. “ mustard, 191. “ salt, 191. “ sulphur, 191, Bath, vapor, 192. Barton's fracture, 138. Bed for typhoid patient, 8. Beef tea, 186 Bile in urine, 198. Biliary calculus, 64. Bilious fever, 21. Bilious headache, 50. - “ temperament, 182. Bladder, diseases of, 69. Blepharitis, 89. Blood in urine, 198. Brain, compression of, 156. - “ concussion of, 155. “ congestion of, 72. Brain fever, 72. Bran bath, 191. Break-bone fever, 19. Bright's disease, 66. Bromidia, 205. Bronchitis, 31. { % capillary, 33. Bubo, 174, 177. Bunion, 172. Burns, 161. CALCULUS, biliary, 64. Calculus, renal, 68. Camphor, Rubini's, 203. Cancrum oris, 45. Capelline, 133. Carbuncle, 159. Cataplasms, 188. Catarrh, nasal, 25. Cautery, 163. Catgut ligature, 203. Cerebral meningitis, 72. Cerebro-Spinal meningitis, 11. Cervix, laceration of, I17. Chancre, 173. Chancroid, 176. Chills and fever, 19. Chloastma, 87. Chlorides, excess of, 198. Chloroform, use of, 166. { { test, 203. Chloral blister, 189. Cholera Asiatica, 98. Cholera infantum, 101. Chorea, 81. Circumcision, 172. Cirrhotic kidney, 67. | Climacteric, 128. Climate, in phthisis, 41. Cocaine, 166. Coccygodinia, 171. 213, 214 IND EX. Cod-liver oil, 187. Cold cap, 190. “ cloth, 190. ‘‘ douche, 191. Cold drip, 190. “ pack, 191. “ lead, 57. Collapse, temperature, 5, ("olles' fracture, 138. Comedo, 87. Compression of brain, 156. Concussion of brain, 155. Congestion of brain, 72. € $ liver, 61. { * lungs, 36. Congestive chill, 22. Conjunctivitis, 89. Constipation, 57. Consumption, 37. Convulsions, 82. Cord, prolapse of, 109. Corms, 172. Cough, 29. . “ whooping, 30. Coryza, 25. Craniotomy, 113. Croup, catarrhal, 28. “ false, 83 “ pseudo-membramous, 28. Cystitis, 69. - * . Cystocele, 108. DEATH, signs of, 205. Delirium tremens, 75. Demulcents, 209. Dengue, 19. - Diabetes mellitus, 102. Diagnosis of measles, 18. “ typhoid, 10. { % typhus, 10. { { scarlatina, 18. Ç k small pox, 18. Diarrhoea, 51. • - Piº in cholera infantum, 102, 186 Djet, in diabetes, 103. “ in fevers, 186. “ for infants, 185. Diphtheria, 96. Disinfectants, 192. Dislocations, simple, 142. * complicated, 143. “ compound, 143. { % habitual, 142. { % irreducible, 142. amkle joint, 146. T)islocation of { { clavicle, 144. ( & elbow, 145. { { fingers, 145. { { hip, 145. { { humerus, 144. { % jaw, 143. { { patella, 146. { % tarsus, 146. $º tibia, 146, JDislocation of vertebrae, 143, § { wrist, 145. IDissection Wounds, 160. I)oses, hypodermic, 202. Douche, cold, 191. Dissection wound, 160. Drinking-water, 195. Dropsy, 95. Duration of pregnancy, 106. I)ysentery, 53. Dysmemorrhoea, 124. I)ystocia, 109. EAR, diseases of, 91. Eclampsia, puerpéral, 114. ; Ecthyma, 87. Eczema, 87. - Effusion, pleural, 38. Egg mog, 187. Emetics, 208. Endocarditis, 42. Enemata, 187. Rever, * { { Enteric fever, 5. Entozoa, 60- Enuresis, 70. Epididymitis, 180, Jöpilepsy, 81. Epistaxis, 26, 163. Eruptive fevers, 13. Erysipelas, 92. Erythema, 87. - Ether, use of, 166. Rye, diseases of, 89. t - - Expectancy of life, 199. " ' ". Expectancy of sickness, 199. IExpert testimony, 183. • FEBRIS icterodes, 23. cerebro-spinal, 11. intermittent, 19. “ jail, 9. “ puerperal, 119, “ remittent, 21. ‘‘ scarlet, 13. “ ship, 9. “ typhoid, 5. “ typho-malarial, 12. “ typhus, 9. Bevers, continued, 5. ( { eruptive, 13. { { periodical, 19. Eissure in amo, 170. Fistula, rectal, 171. Fly blister, 189. Fomentations, 189. . Forceps delivery, 111. Fracture box, 130. - Fractures, compound, 131. { % simple, 129. { { ununited, 132. Fracture of arm, 137. { % clavicle, 135. {{. facial bones, 133, { % femur, 138. { { fibula, 141. § { hand, 138. Fracture of humerus, 136. { { hyoid bone, 134. . . . jaw, 133. ( , nasal bones, 133. Ç G patella, 140. { { pelvis, 138. * * radius, 138. ( & skull, 132. ( & spine, 135. & $ ribs, 136. { % scapula, 136. ( & sternum, 136. ( & tibia, 140. { % ulna, 137. Frost bite, 151. . Fumigation, 194. GANG LION, 172. Gangrene, 159. Gastralgia, 47. Gastric catarrh, 46. “ fever, 12, { % headache, 50. U Q ulcer, 48. Glaucoma, 91. Gleet, 179. Glottis, oedema of, 26. Gonorrhoea, 177. Granular kidney, 66. Granular lids, 90. Gum-Arabic water, 185. Gummata, 176. . HAEMIA'ſ EMIESIS, 49. Haematuria, 71. - Haemoptysis, 36. Haemorrhage, 162. * post-partum, 110. st rectal, 164. $ (. urethral, 164. K \, uterine, 164. Haemorrhoids, 58, 169. Hare-lip, 16%. Hardening oándages, 204. Hay fever, 27. - Headaches, 50, 51. Headache, congestive, 77. § { nervous, 77. { { sick, 50. Heartburn, 47. Heart, diseases of, 42. Helmicrania, 77. Hepatitis, 62. Hermia, 153. Flerpes, 87. IIerniotomy, 153. Hives, 88. Hordeolum, 89. - Hour-glass contraction, 114. Hydrocele, 180 - Hydrocephalus, acute, 84. { { chronic, 84. Tly drophobia, 161. Hydrothorax, 39. - Hymen, imperforate, 108. Hyperaemia of brain, 66, INT).EX. 215 Hypodermic medication, 202, Hysteria, 81. ICE bag, 190. Imperforate hymen, 108. Infant diet, 185. Influenza, 27. In-growing mail, 173. Intertrigo, 88. Intussusception, 168. Iodoform, 203. Itch, barber's, 87. Iritis, 91. “ syphilitic, 91. JAIL fever, 9. Jaum dice, 63. Jurors, 184. KIDNEY, amyloid, 67. ( * red granular, 66. Kidneys, diseases of, 65. Keratitis, 90. LACERATION of cervix, 117. Laceration of perineum, 116. Laryngismus stridulus, 83. Laryngitis, 28. - Lead colic, 57. Leeches, 203. Legal medicine, 183. Lente’s solution, 23. Leucorrhoea, 126. Lichen, 88. Ligature, 162. Lisfranc's operation, 151. Listerism, 154. Lithaemia, 103. Lithiasis, 103. - Liver, congestion of, 61. “ diseases of, 61. Local anaesthesia, 166. Lung fever, 34, Lungs, congestion of, 36. Lungs, Oedema of, 36. Lymphatic temperament, 182. MALPRACTICE, 184. Mania, puerperal, 115. Mastitis, 121. Measles, 15. Meningitis, cerebral, 72. { % cerebro-spinal, 11. Menorrhagia, 123. Mercurial bath, 192. Metrorrhagia, 122. Microscopic urinalysis, 196. Milk diet, 188. Milk leg, 118. Miscarriage, 105. Morphine habit, 76. Morbilli, 15. Mucus in urine, 198. Mumps, 45. Mustard bath, 191. Mustard poultice, 189. 216 - INDEX. Mutton broth, 187. Myocarditis, 42. NAEWUS, 168. - Nail, in-growing. 173. Nasal catarrh, 25. - Nephritis, parenchymatous, 66. Nervous diseases, 72. Nervous temperament, 181. Neuralgia, 78. - - Nipples, sore, 122. Noma, 45. - Nursing, in typhoid, 8. . . OATMEAL water, 185. Obstetrics, 104. GEdema glottidis, 26. “ of lungs, 36. Opium habit, 76. Ophthalmia, 89. &t catarrhal, 89. “ gomorrhoeal. 90. {& neonatorum, 89. “ . . . phlyctenular, 90. Orchitis, 180. - - Otalgia, 91. Otorrhoea, 92. Ovaritis, 127. . Oxyuris vermicularis, 61. Ozana, 25. - “ syphilitic, 25. Ozone, 192. PARACENTESIS abdominis,100. Paraphimosis, 176. Palpitation of heart, 43. Parotitis, 45. Parturition, 107. Pemphigus, 88. Pericarditis, 42. Perineum, lacerated, 116, &Q rigid, 108. Feritonitis, 55. , , . Periodical fevers, 19. Perforation of stomach, 49. Perforation of bowel, 6. Pernicious ague, 22. . . Portussis, 30. - Phagedaena, 177. - Phlegmasia dolens, 118. Phosphates, excess, 198. Phthisis, pulmonary, 39. Piles, 169 Pin worms, 61. Pityriasis, 88. - Placenta, adherent, 114. & C praevia, 109. 6 & retained, 113. Plaster bandage, 129. Pleuritis, 37. º Pleurodynia, 39. Pheumatic aspiration, 169. Tºnellmonitis, 34. ' Podalic version, 110. Poisoning, 208. Poisons, 210, 211. Poppy formentation, 189. Post-partum haemorrhage, 110. Pott’s fracture, 141. Poultices, 188. Premature labor, 1ſ5. Prolapse of cord, 109. Prurigo, 88. Pruritus, 88. * * vulvae, 127. Psoriasis, 88. Puerperal eclampsia, 114. $ & fever, 119. § { mania, 115. Tºus in urine, 198. QUINSY, 45. - Quinine, solution, 23. - RECTAL alimentation, 187. fistula, 171. (, , haemorrhage, 164. {{ Stricture, 170. Remittent fever, 21. Renal calculus, 68. Respiration, artificial. 205. | Retained placenta, 113. Retention of urine, 171. Rheumatism, 93. Rigid os, 107. “ perineum, 108. Rose cold, 27. Rubeola, 15. Rubini's camphor, 203. Rupia, 176. SALT bath, 191. Sanguine temperament, 181. Salmitation, 194. Sarcocele, 176. Scalds, 161. Scarlet fever, 13. Schwartz, solution of, 163. Sciatica, 79. Sex, to determine, 107. Serous cholera, 98. Shingles, 87. Ship fever, 9. Shock, 165. Sick headache, 50. Sick-room, 7. Simple continued fever, 12. Signs of death, 205. Skin, diseases of, 85, 88, Small pox, 16. Snake bites, 160. Solution of §: 23. tº º chwartz, 207. Sore nipples, 122. | Spanish windlass, 163. | Spasmodic croup, 83. Splints, 130. Spotted fever, 11. Sprains, 160. Starch bandage, 130. Stimulants, 208. INDEX. 217. Stimulation, 209. Stings of insects, 160. Stomatitis, 45. Stricture of rectum, 170. urethra, 179. St. Vitus’ dance, 81. Stye, 89. Styptics, 163. Sugar in urine. 198. Sulphur bath, 191. Surgery, 129. Šyphilis, 173. {{. secondary, 175. § { tertiary, 175. $ i. treatment of, 135. TAENIA Solium, 60. Tampom, 105. Tape worm, 60. Teeth, eruption of, 201. “ permanent, 201. “ temporary, 201. Temperaments, bilious, 182. lymphatic, 182. * { nervous, 181. $ (, sanguine, 181. Temperature, 5, 201. Tetanus, 80. Throat cut, 151. Thoracentesis, 168. Tinea versicolor, 88. Tonsilitis. 45. Torsion, 163. - Tough membranes, 107. Tourniquet, 163. Tracheotomy, 151. Transfusion, 206. Trephining, 132. Turpentine stupe, 189. Twins, 113. Typhoid fever, 5. - Typho-malarial fever, 21. Typhus fever, 9. Typhus, abdominal, 5. ULCERS, 157. { * healthy, 157. ū ū inflamed, 158. § { irritable, 158. § { sloughing, 158. Uraemia, 69. Urea, excess of, 198. Urethral haemorrhage, 164, Uric-acid diathesis, 103. | $ excess of, 198, Urinalysis, 198. Urine, retention of, 171. Urticaria, 88. Uterine hæmorrhage, 164. WACCINATION, 17. Vapor bath, 192. Variola, 16. Varioloid, 16. Venereal, the, 173. Venesection, 165. Ventilation, 192. Version, 110. Virus, vaccine, 17. Vital capacity, 199. WATER BRASH, 47. Wet pack, 192. Weights and measures, 204. Whooping cough, 30. Wine whey, 186. Worms, 60. Wounds, treatment of, 154, YELLOW fever, 23. . . . Li ST OF . . . MEDICAL BOOKS PUBLISHED BY GRoss & DELBRIDGE, 48 MADIson streET, CH CAGO. ANY E O O K | N THIS LIST SENT POSTFAID ON RECEIPT of PRICE. REM ITTANCES MAY BE MADE BY BANK DRAFT, P. O. MONEY ORDER, OR REGISTERED LETTER, AT THE RISK OF THE PUBLISHERS. GRoss & DELBRIDGE's MEDICAL Books. Science and Art of Obstetrics, by SHELDON LEA- VITT, M.D., Professor of Obstetrics, etc., in Hahne- mann Medical College and Clinical Professor of Midwifery in the Hahnemann Hospital of Chicago, Member of the American Institiute of Homoeopathy, Vice-President of the American Obstetrical Society, etc., etc. Second Edition, rewritten and enlarged. Large octavo, 799 pp. Price in cloth, $6.00, sheep, $7.00. Postage, 33 cents. A Teact-Book of Motteria Medica, and "herapeu- tics, Characteristic, Analytical, and Com- parative. By A. C. COWPERTHWAITE, M.D., Ph.D., LL.D., Professor of Materia Medica and Therapeu- tics in the Chicago Homoeopathic Medical College. Author of “A Text-Book of Gynaecology,” “Insan- ity in its Medico-Legal Relations,” etc. Sixth edit- ion. Entirely rewritten and revised, with Clinical Index. pp. 834. Price, cloth $6.00; sheep, $7.00. Postage, 32 cents. Chicago: Gross & Delbridge, 1892. A Teact-Book of Gynecology, Designed for the Student and General Practitioner, by A. C. CowPERTH WAITE, M.D., Ph.D., LL.D., Professor of Materia Medica and Diseases of Women in the Homoeopathic Medical Department of the Univer- sity of Iowa; President of the American Institute of Homoeopathy; Author of “A Text-Book of Materia Medica,” etc. Cloth, $5.00, sheep, $6.00. Postage, 20 cents. Chicago: Gross & Delbridge, 1888. Diseases and Injuries of the Eye. A Practical Treatise on the Medical and Surgical Treatment of the Diseases and Injuries of the Eye. By J. H. BUF- FUM, M.D., O. et A, Chir.; Professor of Ophthalmol- ogy and Otology in the Chicago Homoeopathic Medi- cal College. 428 pages. Containing I 50 wood en- gravings and 25 colored lithographs. Cloth, $4.50. Postage, 20 cents. . Key-Notes of Medical Practice. By CHARLES GATCHELL, M.D., formerly Professor of the Theory and Practice of Medicine, University of Michigan; Attending Physician to Cook County Hospital; Author of “How to Feed the Sick,” “Treatment of Cholera,” “Haschisch,” etc. Pocket Book. Flex- ible leather. 217 pages. Sixth edition, revised and enlarged. $2.O.O. Postage, 4 cents. Lectures on Fevers. By J. R. KIPPAX, M.D., LL.B., Professor of Principles and Practice of Medicine in the Chicago Homoeopathic Medical College; Clini- cal Lecturer and Visiting Physician to the Cook County Hospital; Author of “Handbook of Skin Diseases,” etc. 460 pages. Illustrated. $4.50. Post- age, 2O cents. - Skian Diseases and their Homoeopathic Treat- ment. By JOHN R, KIPPAx, M.D., LL.B., Profes- sor of Principles and Practice of Medicine and Med- ical Jurisprudence in the Chicago Homoeopathic Medical College; late Clinical Lecturer and Visit- ing Physician to Cook County Hospital; Member of the American Institute of Homoeopathy; Member of the College of Physicians and Surgeons, Ontario; Author of Lectures on Fevers, etc., etc. Fifth edit- ion, revised and enlarged. 294 pages. Cloth. Price, $2.O.O. Postage, 13 cts. - A Physiological Materia Medica, Comprising the Physiological Action of our Remedies, their Charac- teristic Indications and their Pharmacology. By W. H. BURT, M.D. Octavo. Fourth edition. Cloth, $7.00; sheep, $8.00. Postage, 33 cts, Clinical Companion to “THE PHYSIOLOGICAL MATERIA MEDICA.” Being a Compendium of Dis- eases, their Homoeopathic and Accessory Treatment, with Valuable Tables and Practical Hints on Etiol- ogy, Pathology, Hygiene, etc. By W. H. BURT, M.D. 252 pages. Illustrated. Price, cloth, $2.50. flexible leather, $3.00. Postage, 8 cts, Pułamonary Consumption, its Prophylaxis and Cure by Swralianentation of Liquid Food. By WILLIAM H. BURT, M.D., Author of “Physiological Materia Medica,” “Characteristic Materia Medica,” “Therapeutics of Tubercular Consumption,” etc., etc. Second edition. Price, $2.50. Postage IO cts A Treatise on the Decline of Manhood, or Sex:- wal Newrosis. By ALVIN E. SMALL, A.M., M.D., late President of Hahnemann Medical College and Hospital. Fourth edition, revised and greatly en- larged. Cloth. Price, $1.00. Postage, 6 cts. The Homoeopathic Veterimary Doctor. Giving th: History, Means of Prevention, and Symptoms of all IDiseases of the Horse, Ox, Sheep, Hog, Dog, Cat, Poultry and Birds, and the most approved Methods of Treatment. By GEORGE H. HAMMERTON, V. S. Octavo. Cloth, 535 pages. Price, $3.OO. Postage, 22 CtS, Philosophy of Homoeopathy. By CHAS. S. MACK, M.D., Professor of Materia Medica and Therapeu- tics in the Homoeopathic Medical College of the Uni- versity of Michigan. Addressed to the Medical Profession and to the general reader. I74 pages. Cloth. Price, $1.25. The Physician’s Chemistry. By CLIF FoRD MITCH- ELL, A.B., M.D., Author of “Student's Manual of Urinary Analysis.” “Clinical Significance of Urine,” “Practitioner's Guide to Urinary Analysis,” 1886. 3OI pages. Price, $1.50. Postage, IO cents. Practitioner’s Guide to Urinary Analysis. By CLIFFORD MITCHELL, A.B., (Harv.) M.D., Professor of Chemistry, Chicago Homoeopathic College; Au- thor of “Physicians' Chemistry,” “Manual of Uri- nary Analysis,” “Clinical Significance of Urine,” “Manual of Simple Chemical Tests,” etc. Third edition, thoroughly revised, 12mo, Cloth. $1.50. Postage, 8 cents. The Americatºv Homºoeopattlvic Dispensatory. De- signed as a Text-Book for the Physician, Student and Druggist. By T. D. WILLIAMS, M.D., Member Illinois State Pharmaceutical Association, Active Member American Public Health Association. 713 pages. Octavo. Half leather, $4.O.O. Postage, 3 cents. A Manual of Peneveal Diseases. Being a Con- densed Description of those Affections and the Homoeopathic Treatment. By E. C. FRANKLIN, M.D., late Professor of Surgery in the Homoe- opathic Department of the University of Michigan; Surgeon to the University Homoeopathic Hospital; Author of “Science and Art of Surgery,” “A Com- plete Minor Surgery,” etc. Octavo. Price, $1.25. Postage, 7 cents. Ruddock’s Family Doctor. Being a reprint of Dr. Ruddock's “Wade-Mecum,” “Diseases of Women,” “Diseases of Infants and Children,” and “Essentials of Diet.” With Notes and Additional Chapters, by JAMES E. GROSS, M.D. 772 pages. Octavo. Cloth, $2.OO, Postage, 30 cents. Antiseptic Medication or Declat’s Method. By NICHO FRANCIS COOKE, M.D., LL.D. Second edi- tion. Cloth, $1.OO Postage, 5 cents. The Baby. How to Keep It Well. By J. B. DUN- HAM, M.D., Cloth. 50 cents. Postage, 5 cents. The Physician’s Comdensed Accowavt Book. An Epitomized System of Bookkeeping, avoiding the necessity of separate Journal; Day Book and Ledger, Combining system, accuracy and easy reference with a minimum of labor. 272 pages. Price, $3.50, net. Sent postpaid. Send for sample page. The Physician’s Day Book, and Ledge”. Ar- ranged by T. D. WILLIAMS, M.D., Author of “American Homoeopathic Dispensatory.” Price, $2.OO, net. Sent postpaid. Sample pages sent on application. JLabel Book, FOR THE USE OF PHYSICIANS AND PHARMACISTS. Containing more than thirty-five hundred gummed labels in large, clear type, and bound in a neat and substantial manner. Price, 50 cents, net. Sent postpaid. GROSS & DELERIDGE, Publishers, 48 Madison St., CHICAGO. "modbyPreseneton 1990 ș§§§§§žģī£7：£????ŅŠ ſå →L.\ſ*®sº ſºł "№.§）,*** TaezȚ75，5 ± √3-----：-3，77-№vgº@vae-&& !º ≡≡≡ŻĘzg（N75@₪zgºwyſ; gael ¿? }}*： #„x”ž” o’º· .f., 4. §„~~~~， º jºſſ,!$$,&~ SÝ Ú. ·'，·|-* ģ gºſº, ºſ*...- ș.• .}+ \, ^x, *…'? №！，• 5 : * ·*-Cf; */\, ，Ź·、、 、、、 *） №!"??A;: ·! *ſ*.**.* f \，.`§. 7 aelº №s„ .，.:.，，,,Viſº ，x*| *） ;x \ , \,,^; &ººººº^{*ş k.º.º.ș*ſ*., , *→Ķ£, gºłº** º * , , **ş•';*įºſº）, £§§§§§§©®°¶√≠√¶√≠√≠√∞ √≠√∞ √≠√∞ $§§§§§） ſº ºff， №ğffºſºſ，¿ Åșº,Ķī£3§3?\}， …§}§•*#ffș，šķż§)，ſò èſ , , T,37§§3！}{} \; ，Vă.（\ % ::----**~~）; ºſ*} ~&&ő<！-- *： *****）， §.**∞ √°√（: ,··3,3!！！！！！·*ŠŒx,y \} ×-！， →-];~→:*** ģ*.. ' „Jºžº«，»-！}} < --★！ c）$,，,，…）,！ºji*§Ď3.-*{A}{\\}\\&##§ą łº,，，，,{^-,}}{{A}\~}&}•{•��*ºſºſvișá ºſº?>,*……….Słº,*ae/}}\}，.ae??#3,%>>#*K. · *;*§-ſ ſ”）. §§©®£ ↓¿?Ķg§§ſyyſ” (）…º *）： 2?JŠS Ģſ. ∞)§§7) *** ?? ~~§, |-ſºšº: tº.;Tºl· ·:~}; \,į*:）*&& s），še.&}¿?ș À ſº? ¿¿ {{3！?（S). 2. ºſ.”ŘÍŽ），§3º# ^）;·{№}>ºg sº，Vý %ğ，ºy-£3.Řºg_źr §§ºſº y №. ！>|- }} * ·'）;ī£ſºſ,<！-- » Žijſ!!§§§§§§§§§§§§§§§§§§§§āſ%ſ，%ſ，%ſ，%s*$§§§āſ ſae;#3$$$$ §' ſ. r.\'';、。\ſ*（~~&\!\\S$ſ\'，%įº$#@!„ŽŮ; №<``，``\,k§§§§%~*~§§§§ĻŅĢgºſº, №vº，ĶĒŽĎÁ№ſ.}}}°№ſſº,%%ſººſŹ№（)Ļº ºgg Œyº！!… * *{ {r'}）（）;# .. ° 7 Aºſ 2 <（~;?\ſ?）\;3, ±（√°(Y4,• A \%> <！--rſſ\'ºſſi, ſ);*）$. （* „*№. --& {j/2） <ř~\~\~\~\}{...}， &§ → · § ”ſº,，,） <！~%（ºfii, ſýžģ·T., ºſſ? /…. -3，-2， ºg, ¿??¿2，2%， ŽĢģĶķĻļŅĢºſ:{}}}， žŽÍ， ****-**..., −, ×××· №ſae? №, ??！!?!！!.>-é. -{$s;（ºº） º sg };*ºſ_ºrºs, ���***ť}} **$）/g, №gº?**,-ſ_x - º !•” ！”-! ~- -（. . »¿C?¿?}Y，į.→įºa-¿��'ſ T}.æ-¿-Șº}\\șºc.s.?? ſ^»* -«.… --., ， （**）#%£<;* x§;---）|-i)|- §§§©®°¶√≠√∞X®"№ķī£X®，6%ſ，%ſ，%s，%ſ，%ſ，%ſ，%ſ，%ſ,%ſ，% \}）$x）（$$$$$$）;ęzſ- ---- - - - ….“¿ $$$$（'%ſ\'，%ſ). ... ：（ ！$ {*&& （№șlae} （）, jº:- ºņi{}）（ *）^4 &§ 4;''{ſ- *¿¿.（?， ?） 7^{ſ}-№ț¢ £” ſåſº \,·2} + … *~{-}x_º * ?. ș№ù Šįſº$（******=+ × 3） *** Arç = --- » , «- - - ~- - - - - ~------------ * *<\{ ，ș~\~\{…?Ķ:**§.T ſº}}~~\*， \， ; ）, №8_{T} ~* №ºr √° ***（??, ~）;'）;; ???）， →→→ + v* --~~*~~~~ ~~~~---- - - ----- ``{£é，ķ<ºàº·řº.�f\！}.* <{{¿z.-！&z！*` №ſſ¿?，$2：$）']， º Tºzſ-ya --~--~~" \ý <！--ș，- -№ºººº,,， ,ſ}\;-} ：-） ：-（.**•+'R Ç73;-\ſ*）（?:\s）, º-º „º;>{·}< >4<^.*Z^\$4$. „-\; ŠĶĒĶĒŠºžę， iš №šķğ ºğºčș，âț¢&№ſſºſºſae?¿¿? ·¿??¿ $}{3~$！ 2«; i º., a ſº ſlºvº，_№= §§§§）, ºſſ,%ſ，%ſ*źº， •-，-ºv º šº•# ſº ºsae »<！, ſººs•* •. $. （§！« j ºg§§§ýž§§§§ás$$$2%ſ，%ſ(3 §）§§2: „ſº*--- -·¿??¿ºíſ?（&&！ *）（\<--! *\frá. „№rž，§， №g ſºſyº-ºxºſz)? ¿?\\}（?：ſtarºſs-ºff &.*?.“ºff?）$|（r,r，，。、、） ſº ': *（?:#ffff? （¿>ğ Ř;ĒĢº ！.!.!Ķſºr， sº|-$ſ.&&�* 43.3° №*、、、、、。°）， šº ģ* º * ſ;Źſ*§§§），Ř， ř. №º & &（?！?！???§§§\ | }.&#， ſº 4-ºſºg&#№sº cº?‘“Sì， * ?,„…ºſ, čº!！!ſ;};}-3，3，** \ſ. Šº ſºšJ’’. ,,，,，, ，,ſ} \!\,}_&#*******~*=~·İ,• aerº-z-*<\ *¿.*;;.ſº$_nº！ºtº _№w či ***~…！S）;*-{**… …）; **Ñ&?, ~17!！!*№ſ. À** : £ 1,3 .... 4 *.-· ， !·_Ãżįºſ:|- 。 ∞， -∞, ∞ --~~~~..…|…'. '* .. . . . . . . . . . . . . '--º º-'. , ' . B，C，…！！！！！！！！！--><！---。、。。--……..…...…..….…... .* * , · · · · · · · 3. … … ;-） ….… .4. . . . . .，.：.