note tympanitic in quality (Skoda's resonance). In the hepatization stage the percussion note is flat, but not the wooden flatness of effusion-the resistance is not so great. By auscultation, in first stage we get quiet suppressed breathing in the affected part, and at the end of inspiration fine crepitant rales; in taking a full breath crackling sound close to the ear (broncho-versicular). In red hepatization we find, when dullness is well defined, blowing, tubular breathing without rales. In consolidated lung we get the voice sound transmitted-bronchophony or egophony. When resolution begins we find mucous rales. The picture is so well marked, clear and well known, there is no occasion for error in diagnosis, except in intercurrent pneumonias, and in children the severe cerebral symptoms might be mistaken for meningitis, the initial chill being absent and the disease_ushered in with convulsions. In very old debilitated people, in the beginning the symptoms are not clearly defined and requires very careful examination to get at the actual condition. In old drunkards the disease is marked by the cerebral symptoms resembling delirium tremens. When called to see a case of pneumonia, the fact that I am powerless to cut the disease short does not for a moment cause me to think that I have nothing to do, but puts me absolutely on watch for every symptom, for the expectant and symptomatic plan is all that is left me. The first duty is to relieve pain. This I generally do with morphia hypodermically and local application to the involved lung, giving preference to the ice bag; but in some cases I find heat more satisfactory, and then I use flannel saturated with turpentine over the seat of pain. Iron in well with a flat iron frequently, according to pain and involvement. While this may be no more effectual than poultices, it is much more cleanly and convenient. When I have succeeded in securing my patient's comfort from local pain, I see to getting the best appointed room the circumstances will allow. The bed, ventilation, heat and light inspected, clean, hard, warm bed, heat about 70°, light placed so it will not reflect on the eyes, not strong but about the same all the time, thermometer in the room to guarantee equal temperature, near 70° room free from dust as possible, company positively prohibited, etc. I see that the bowels and kidneys are kept open, I have from the first a bed-pan and urinal (rubber) used, not permitting my patient to get up to pass urine or feces. I see to the diet, giving emphatic orders what I want my patient to eat, the amount, and when and how I want it served. I depend on milk, beef juice, eggs and broths. I see at each visit how it is being prepared and served. I want my patient gently sponged every other day and clothing changed, seeing in the beginning that the night shirts to be used are fixed so they can be changed with least possible disturbance to patient. I use every effort to do away with the fear the laity have about cold applications and drink, and see that the patient gets plenty of water internally and externally. It is almost impossible to have these orders correctly carried out unless you have a professional nurse, and I have one in every case, where possible. I examine my patient thoroly at each visit. I have tried to learn to do this with as little disturbance to my patient as possible. I never make examination in the presence of a room full of neighbors to advertise myself, but for the benefit of the patient. the patient. It is absolutely necessary to make out the stage and amount of involvement, engorgement, hepatization and resolution, for it may extend to all the lobes or both lungs (double and massive) or we may have retarded resolution. Note carefully the respiratory, circulatory and cerebral symptoms. Be on watch for the first appearance of any complication. All this is absolutely the only guide to "management" and prognosis. In my opinion but few trustworthy medicinal agents are at our command to do battle with in pneumonia, hence will consume but little of your time and space in closing this article. The point of danger, so well known, is progressive cardiac weakness, this being caused by the toxic action of the poison gradually produced during the pneumonic process, the fever and overdistention of the right chambers of the heart. Having no known medicinal remedy that will I counteract or neutralize the action of this poison, our task is to lower the temperature and support the heart. recognize high and prolonged fever as hurtful and dangerous, but we are called upon here to select the lesser of the two evils. It will not do to fight down the fever at the expense of the heart, and my 12 years experience at the bedside teaches me that is what we do when we use medicinal antipyretics. I have some cases that would bear them, but at the expense of the heart just the same. To control the fever I depend absolutely on water and cold applications. I have my patient to drink plenty of cold water to eliminate, and when the temperature is as high as 103° I have them well sponged until the fever is lowered. When the temperature is up to 104° or 105° with aggravated cerebral symptoms, I give my patient a bath-water about 70°-and to avoid getting up I use a "rubber sheet" for my bath tub, getting the four corners held up by assistants. I can give an effectual bath with a very small degree of disturbance. I use ice coil to the head and some form of opium to control continued cerebral disturbance. Strychnia is my standby as a heart tonic. I give it hypodermically in 3 gr. to gr. doses as indicated. Where I can not get a nurse to understand how to use the hypodermic syringe, I use aromatic spirits of ammonia. When I meet a hide bound Kentuckian in consultation the tug of war is on. He is opposed to water for anything except for boats, ducks and fish to swim in. He wants good old Kentucky Bourbon internally, externally and eternally. But I have hit upon a way to a compromise. I simply suggest to him that some of our most erudite doctors have studied out and discovered beyond a doubt that "all alcoholic stimulants are contra-indicated-indeed hurtful and exceedingly dangerous-because it is only ignorance of the true effect of alcohol that causes it to be called a stimulant, when in truth it is a narcotic poison, and diminishes the sensibility of the nervous system and functional activity of the glandular system." Of course a Kentucky doctor will not take to this like a duck to water, but I make this proposition; when the fever is high, let us give him plenty of water externally and internally, and when the pulse begins to get feeble and heart sounds less accentuated, let us give him plenty of "old Kentucky Bourbon, internally and externally to tide over the crisis." Agreed-and I do not think any thing like it. I have met some cases of retarded resolution and have most satisfactorily met the indications. with carbonate of creosote, and very small doses of pilocarpine. It induces leucocytosis, stimulates glandular activity, and causes a certain increase in the amount of water separated from the blood in the lung cells. The predisposition to pulmonary tuberculosis is interesting and significant, but space forbids. I have seen pneumonia in full blooded men with high fever and bounding pulse, that it seemed to me the best possible thing that could be done would be venesection, but I have never bled a patient in pneumonia. I have tried arterial sedatives and medicinal antipyretics to my satisfaction. I may find an indication for them in some cases of pneumonia. If I do I will use them without prejudice. In answer to your question: "What are you doing and how are you doing it?" with your permission, as opportunity offers, I will give it to the readers of THE WORLD in broken doses as small and palatable as possible. Please find my $1.00 inclosed. I love quail on toast, but eagle on silver with 16 to 1, E pluribus Unum, and In God We Trust I like better; but I gladly part company with this 200 center for THE MEDICAL WORLD for 1898. J. D HAMILTON, B. S., M.D. Grahamton, Ky. Knock-out Drops. Editor MEDICAL WORLD:-I saw in THE MEDICAL WORLD of a few months back some inquiries about "knock-out drops." I was a coroner at one time for three years, and held views and inquests on a number of persons that were found dead in the Delaware river and other places. A number of these persons were supposed to have died under suspicious circumstances, especially those found in the vicinity of Gloucester City, a famous gambling and racing resort. I gave some attention to the subject of "knock out drops" about that time, and found that the drops were) composed of hydrate of chloral and water. A dram of water will very readily dissolve sixty grains of chloral. A two dram homeopathic vial could be readily carried in the vest pocket and handily used without attracting much attention, and could be manipulated and concealed in the hand. It could be poured into a glass of whiskey, wine, beer, or other drink without noticeably affecting the taste or color of the drink. Cocculus indicus could not be satisfactorily manipulated by a crook; it would be bulky and have a taste. Laudanum is sometimes used, but crooks are afraid of it and fear detection-smell of opium, contracted pupils, analysis, etc. Hyoscyamine and hyoscine could not be procured without fear of detection. Chloral can be procured easily by various devices such as the claim that they are in the habit of using it-got in the habit of using it for neuralgia, insomnia, etc., but they generally get it "for a relative." Frequently they stand in with a druggist or drug clerk who gets it for them. I also learned that in houses of ill-fame where liquors are sold, it was a common practice to add snuff to the whiskey (in bottle); it then produces a sleepy sort of feeling which they think promotes the sexual desire under the influence of certain environments. I like THE WORLD better than any of the other medical journals. I think "Office Talks" would be a good heading for one of your departments. A practical worker in the profession can pick up many a useful idea by reading in THE WORLD the brief lines of interchange of thought, without wading thru much "wind." Camden, N.J. G.W. HENRY, M. D., Ph.G. [Nearly all the matter in THE WORLD is intended as either "office talks" or "bed-side talks." For example, the above communication might be called an "office talk." We want more like it.-Ed.] A Case of Tubercular Meningitis. Editor MEDICAL WORLD-I have just written a death certificate in the case of a male child, one year old, that died from tubercular meningitis. It was a first and only child. Some features of this case may not be without interest. I first saw the child on the 18th of January last. He had been ailing for a week. There was obstinate constipation and persistent vomiting that could be neither well accounted for nor relieved by domestic remedies. Before this illness he had been strong, well-nourished, healthy and good-tempered; but now he was fretful, wakeful and peevish, with capricious appetite. It required the entire attention of one person day and night to attend to him. All this trouble was ascribed to teething, the upper lateral incisors being next in order. Examination, however, revealed no indications of coming teeth. The general facies of the child pointed to some grave malady. The anterior fontanelle was bulging and the pupils were unequally dilated. On the third day, convergent strabismus appeared, no convulsions having been noticed by the young mother. Slight fever. Tache cerebrale not demonstrable. Diagnosis, tubercular meningitisprobably. probably. Later appeared photophobia, widely dilated pupils, rigidity of the muscles of the neck. Automatic movements of the arms, disturbance of hearing and sight, cry hydrocephalique, coma, death in about four weeks after the beginning of the disease. Treatment, symptomatic and palliative, with little expectation of cure. The only such case that I ever saw recover, and in the light of later knowledge I doubt whether that was tubercularwould better have died, for the child became idiotic, ugly, beastly, a living torment to family and friends. Etiology: This child was nursed by his mother, but as she had an insufficient supply of milk, its natural diet was supplemented by condensed milk as required. The child had thriven on this dietary. I had no doubt of my diagnosis, but it was not easy to trace the source of the tubercle bacilli. The parents and their ancestors on both sides were healthy people, with no history of tuberculosis. Finally a clue was found. Last summer when in the country, condensed milk not being readily obtained, the child was fed upon cows' milk from the dairy. It was not sterilized nor pasteurized. It is further in evidence that some of the very same cows were mysteriously sick, and a visit from the State Dairy Inspector revealed that some of the herd were suffering from tuberculosis. With this chain of facts established, it is not difficult to see just how the disease was acquired how the bacillus of tuberculosis reached the meninges of this child. It is by no means improbable that in the country as well as in the city, some, at least, of the children that are carried off by obscure, indefinable diseases, the ailment being often attributed to dentition and its complications. Some of these are really cases of tuberculosis derived from infected milk. This is another illustration of the danger of using crude milk for infants, even in the country, where the source of supply is not known to be beyond suspicion. How much greater is the danger in large cities, where it is almost impossible to say where the milk comes from, and to what exposure it is subjected from the time it leaves the cow until it reaches the consumer. Brooklyn, N. Y. BENJ. EDSON, M. D. Fluids Used in the Injection Treatment of Hernia. Editor MEDICAL WORLD:-Your request that I write another article giving the different formulas used in the injection treatment for the relief and cure of hernia is willingly complied with; but I regret my inability to offer a larger variety. I endeavored to secure additional formulas from the physicians who are giving the treatment; but most of them have territory or fluids for sale, therefore they keep their formulas a secret; and those who would give the desired information are using the secret preparations. My reason for not mentioning the secret proprietary fluids before was due to the fact that many of the readers might think I was insterested in their sale, which I am not; therefore I simply mentioned that I had used some of them with gratifying success without mentioning their names. I have used a number of fluids, both secret and known; but have not found a fluid that gives me entire satisfaction in Dr. Heaton recommended the follow ing formulas, known as the "liquid " and "solid." The liquid" is composed of half an ounce of Thayer's fluid extract of quercus alba, triturated with the aid of gentle heat with fourteen grains of the solid alcoholic extract of quercus alba, adding the sulphate of morphia in the proportion of a grain to the ounce. To make the "solid," add sufficient id. ext. quercus alba to form a thick paste. The quantity to be injected is not given, but I suppose from 5 to 12 minis of the "liquid" and 1 to 3 of the "slid.” I have been successful with the following: R First, reduce fl. Ziv of the fld. ext. fl. Zj m.ij M. Sig. Inject 1 to 3 minims, repeating when reaction has disappeared. I frequently use the following for children and special cases: have used the hot water bag more or less for four years and find it lessens the pain, prevents the liquid from gravitating into the scrotum along the cord, and causes a quicker action of the fluid. I failed to mention, in my previous article, the length of time required between the treatments. My rule is to allow the effect of the previous treatment to disappear before giving another, whether it takes a day or a month. All depends on the fluid used, and the amount of reaction produced; but generally from four days to two weeks. The number of treatments required depends on the fluid used, and the variety and size the hernia opening., Continue treating till all evidence of weakness has disappeared. Do not test results too soon, and be sure to have the patient wear a proper support. C. FLETCHER SOUDER, M. D. 1607 Arch street, Philadelphia. A Case of Hyperesthesia, Following Frost- Editor MEDICAL WORLD:-The following case, altho not unique, has many interesting points in several respects, and I therefore deem it of sufficient interest to submit it for publication. Patient, a young man, in the early part of last November, after a somewhat prolonged spree, went to the barn to sleep over night, and when he awoke in the morning was hardly able to walk, having frozen a foot. He was carried to my office, and upon examination I found all the toes and surrounding tissues black, gangrene having set in. I thought amputation indicated, but decided to wait. I dusted over the affected parts equal parts of boracic acid and acetanilid freely, and protected the foot with suitable bandage. Gangrenous tissue was soon thrown off, but fortunately the ulcerative process was superficial only, and in the course of a few weeks the foot healed kindly. However, the patient was unable to step on it on account of a severe pain it caused; in fact, the entire foot below the ankle was decidedly hyperesthetic. I then treated the entire foot with dry hot air, subjecting the entire foot for 25 minutes to a temperature of 350° F. daily. After five treatments the pain disappeared and has not returned. The apparatus I used for that purpose is made by Messrs. Frank S. Betz & Co., 80 State St., Chicago. The points of interest in this case suggesting themselves to me are: First, do not amputate every toe afflicted with gangrene from frost-bite without giving the patient the benefit of conservatism. Second, was the hyperesthesia in this case due to an exposure of the sensory nerve filament? or was an inflammatory condition the fault? Third, if the former be the case, intense dry heat applied sufficiently long is a local anesthetic; if the latter, it is the most prompt and pleasant local antiphlogistic known to medical science, even if the inflammation is deep seated. J. C. R. CHAREST, M.D.. Lamberton. Minn. Questions Concerning the Treatment of DR. WILLIAM F. WAUGH:-Will you please tell me thru THE MEDICAL WORLD: Ist, What remedies you use in tuberculous diarrhea, for both hyperemia and ulceration of the bowels? 2d, When you give iodoform and sulphocarbolate of calcium do you not meet the indications for iodide of calcium? I have used the calcium salts in tuberculosis; have never used iodoform. 3d, Who makes the sulphocarbolates you use? I have been using that made by Chas. T. White & Co., New York. I want the best. My dear sir, I think you can be to the general practitioner what Karl Von Ruck is to the specialist, in writing on tuberculosis. Serum therapy is out of the question, I think, in tuberculosis for the general practitioner. There is a woeful lack of interest among the most of us in regard to that dreadful disease. The average doctor tells his patient to go west, prescribes a cough syrup, cod liver oil, and tells his neighbor that Mr. C. will die sooner or later. If he seeks advice from another doctor he is given a tonic, more cod liver oil and told to move if he can dispose of his property; that the climate does not suit him. I was guilty of the same thing until my niece |