Asthma. By W. O. BUNNELL, M. D. Wilkes-Barre, Pa. The name of this disease indicates accurately its character, "I breathe with difficulty." It is one of the most difficult diseases to successfully treat that the physician has to deal with. It depends in all its forms upon some interference with the free entrance and exit of air to and from the lungs, and this is generally, if not always, dependent upon a spasm of the muscular fibers in the walls of the bronchial tubes. It has been proved that the spasm is due to a neurosis of the pneumogastric, or vagus, nerve. Symptoms. Usually it comes on gradually, attaining its greatest violence in two or three days. The attack is generally preceded, for a day or so, by a loaded tongue, pain and weight in the head, a feeling of languor, pain in the muscles, and nausea. But in some cases there are no premonitory symptoms. It is sudden in its onset, the patient being roused at night by a feeling of impending suffocation, and is forced to throw open the windows and doors in order to get breath. The paroxysm is variable, sometimes lasting but a few hours, at others, days or even weeks. Its recurrence, too, varies even in the same cases; in some the patient is hardly free from the disease from autumn until summer. But in some rare instances the patient having the one attack arrested may never have another. But in a large majority, the disease becomes constitutional, and recurring attacks of asthma are the result of any indiscretion, or sudden change of weather. Diagnosis. The difficult breathing, with absenoe of febrile symptoms, is sufficient to determine the character of the affection. If not, the previous history of the disease will make the case plain. Prognosis. It is not classed among diseases likely to prove fatal, though it does occasionally terminate the life of the patient speedily. In fatal cases there is usually some organic affection of the heart. It is one of the most difficult diseases to cure radically that the physician is called to treat, and possibly in one-half of the cases we meet, if confirmed, the treatment will be merely palliative. Treatment. into two classes, palliative and permanent, the first having reference to mitigating or arresting the paroxysm, the second to removal of the cause, and in this way effect a cure. The treatment of asthma is divided Palliative Treatment. The quickest way is to give, hypodermically, morphine 4 gr., and atropine 1-100 gr. Also chloroform by inhalation, 20 or 30 drops on a handkerchief, and carefully inhaled, is used with great success. Paper, soaked with a saturated solution of nitrate of potash and then dried, is burned in the room so that the patient may inhale the smoke. In most cases this will give instant relief. Amyl nitrite by inhalation, 3 to 6 drops on a handkerchief, has been very successfully used in arresting the paroxysm. Belladonna and lobelia in full doses are also used. The smoke of tobacco is very efficacious in those who are not accustomed to it. Cocaine hydrochlorate gr. 16, aquæ 1 oz., used as a spray to the nasal cavities and throat, will often give very rapid relief. After the paroxysm has been arrested, the cause must be found and removed to make a permanent cure. Curative Treatment. Many plans of treatment have been recommended for the permanent cure of this disease, but as yet without flattering success. The diet must be light, and bowels be kept open. As the attacks are generally nocturnal, the evening meal should be taken early, be light, and easily digested, and tea and coffee should be avoided. The patient should avoid dust, and ought to live in the open air as much as possible. Damp air is usually preferable to dry, if it is not too cold. But this rule is subject to many variations, and each case will be found to be a law unto itself, and each patient must try different climates until the proper one is found. The fluid extract of grindelia robusta, in doses of from 15 to 30 drops three times per day, is one of the best prophylactics we have. Asculus glabra has also been similarly used with success. Outside of hygienic measures I have used the following with the greatest satisfaction: R Tinctur. phytolacca Syrup. simpl. 3ss moved by enema and the urine drawn with a soft rubber catheter. Patient was placed in lithotomy position, antiseptic vaginal douche given, the parts shaved and cleansed with bichloride, I to 1,000. It being decided to attempt the operation under the influence of a local anesthetic, a 4-per-cent. solution of cocaine muriate was injected, using some four or five minims on each side of the floor of the vagina, and the surface of the M. Sig.--One teasponful after meals and at bed- vaginal floor repeatedly painted over with time. TO THE MEdical CouNCIL: Mrs. E., primipara, age 23; rupture of the third degree, viz., extending through the sphincter ani; caused by excessive uterine contractions and use of instruments. She had been in the hands of a midwife, who called in a physician, who, in turn, sent for Dr. J. H. Robinson to do the operation. Primary operation was not feasible on account of room, light, etc. Eighteen months later the patient miscarried in her second pregnancy at the end of the third month. There was prolapse of the uterus of the second degree. One month previous to operating, she was given general tonic treatment of iron, quinine and nux vomica. Five or six days before operation Epsom salts were given every twelve hours to clear the bowel, and the vagina was flushed morning and night with carbolized water. During this period a fluid diet, so far as practicable, was directed. On the morning the operation was performed, the bowels were the same. It was necessary to repeat these injections and paintings two or three times before the work was terminated. With a pair of scissors, curved on the flat, the old lacerated surface was revivified, commencing below and working upward, to prevent the flow of blood from freshened surfaces blinding the field of operation. As little tissue was sacrificed as possible, care being taken to have a smooth raw surface. This being done, five strong silk deep sutures were put in, beginning below, at the margin of the anus. A strong needle, curved on the flat to prevent wounding the rectum, was used. Of course one finger of the operator was kept in the rectum all the time, the labia being held apart by an assistant. The slight hemorrhage was readily controlled by pressure. The needle was made to enter the skin about three-eighths of an inch from the margin, carried beneath the dennded surface, and brought out at a like distance on the opposite side, except the last two sutures, which passed through the angle of the surface, catching it up in like manner on the other side. The deep sutures being tied, a few superficial ones were put in to approximate the cutis. A soft rubber catheter (which was attached to rubber tubing to discharge urine into vessel under the bed) was fixed in the urethra, the vagina was douched with carbolized water, and the perineum dusted with iodoform and boracic acid, and covered with sublimated gauze and cotton, all being retained with a T-bandage. The woman's knees were tied together and she was placed in bed upon her back, with her knees flexed over a pillow. For the following four or five days the stools were prevented by small doses of opium, and the patient given a fluid diet. At the expiration of this time the bowels were moved by enema, and the catheter was permanently removed, the vagina douched, and the wound dressed. It was doing nicely, no sign of suppuration any where. At the end of eight or nine days the sutures were removed. No dressing other than a sterilized napkin was applied after the catheter was taken from the bladder. However the douche was continued for a considerable time, and care exercised to prevent straining the parts repaired. At the end of thirty days she was well, the parts, apparently having healed oy first intention. The patient belonged (so far as the operation was concerned) to Dr. John Robinson, of this place. I was called to assist him. J. R. BOYD, M. D. Oakvale, W. Va. A Word About Strangulated Hernia for the Country Doctor by a Country Doctor. TO THE MEDICAL COUNCIL: During the eight years of practice since my date of graduation, I have had three cases of strangulated hernia, i. e., hernia that could not be reduced within twelve to eighteen hours by taxis, enemas, and various local applications, and where vomiting, hiccough, and constipation persisted. My first case occurred within a few months after I first hung out my shingle. My consultant, himself the son of a prominent physician, and an European student, sent for by me to come and operate, favored delay, opiates, and various milder measures in the hope of coaxing the bowel back into the abdominal cavity. And I(?) well, I must have been weak or overawed, because I consented to the delay. The result! There could only be one-the patient died. The other two cases, both occurring within the last year, were operated upon by myself, and with the happiest result. One, about thirty hours after the strangulation, the other, about sixteen hours. And now, looking back over the field, what is there in this operation from which the general practitioner should shrink? I do not mean to deprecate the value of a fully-equipped surgical outfit, but as this is not possible in the great majority of homes, you can-with a scalpel, a probe-pointed bistoury, a pair of tweezers, a pair of scissors, four or five artery forceps, all of the aseptic type, half a dozen curved needles, some catgut sutures, or, better, kangaroo tendons, a washboiler full of boiled water, and a couple of barrels with plank for an operating-tableperform an operation that will save the great majority of your patients. So call in the nearest physician that you are on speaking terms with, or, better, two of them. Place your instruments and needles in a clean towel, and suspend them in boiling water for ten minutes, have your assistants place the patient upon the improvised table, and with a razor prepare the field of operation. While they are doing this, do what you can to sterilize your hands. Use the nail-brush and plenty of soap and water, changing the latter frequently. Then, if you have alcohol or ether, use that on the hands, and end by immersing for several minutes in a 3-per-cent. carbolic-acid solution or a 1 to 2,000 bichloride solution. Next, subject the field of operation to the same process, surround it with several aseptic towels, and you are ready to operate. Make a 21⁄2-inch incision over the external ring on a line with the long axis of the tumor. Then go slowly and carefully. Don't look for the different hernial coverings as laid down by Gray. "Cut right through the Latin names and get to the gut." Then carefully divide the muscle for an inch above the external ring. Then insert the finger into the internal ring alongside of the hernia. You may be able to sufficiently enlarge the opening with the finger to allow the return of the gut. If not, a few nicks with the bistoury will suffice, and the worst of the job is over. By this time, if you are feeling at all timid, don't bother further with the sac, or you may place a catgut ligature around it and leave it in situ. Take two or three stitches through the internal ring and the muscles overlying the canal. Close the external wound without drainage. Put on a good dressing, and leave your patient in the hands of Providence. Whatever the result, you Whatever the result, you have done your duty. I know that many a surgeon with a well-equipped hospital within easy reach will smile at these suggestions, but if the country physician, far removed from these advantages, toiling anxiously over the bedside of a suffering patient, happens to find in them sufficient inspiration to nerve himself up to his duty, I will feel amply repaid. 3. Profuse politeness on the part of a doctor counts for little. The doctor that is too busy to be over-polite is apt to be preferred. 4. The main things for a country doctor to know is how to handle fevers and stop pain; how to handle an emergency and act promptly; also how not to say too much. 5. Flattery never pays in the long run. Do not call the homely, dirty child lovely, or make the granny think she knows it all. 6. Don't be in a hurry to tell people that they cannot be cured. When asked by 'Squire Pike, who has "rhumatiz," if you can cure him, say: "Oh, possibly," and talk of something else, or tackle his case at once. 7. It is not well to seem anxious to get cases. It is better to seem to be overloading yourself by accepting them. 8. There are plenty of old chronics everywhere who never got well simply because they never took treatment or medicine perseveringly enough. 9. If you refuse to treat these people at first, and state that your only reason is because you think they will not stay with you long enough, at last, when they do take your treatment, they may improve somewhat by faith, if not by the medicine. 10. Once I said to a patient: "Here is the medicine that, if rightly taken, can cure a case like yours, but I might as well throw it away as give it to you, for you will forget all about it in three days." II. If a patient is slow to get well under your treatment, never take a particle of blame to yourself, and, by all means, never blame the medicine if there is a way out. 12. If Mr. A. gets fresh air and red tablets, and the fresh air saves his life, give the glory to the wisdom that selected the red tablets. 13. Folks don't like to pay doctor bills for being told to eat this or that, do so and so, and getting lectured on hygiene, whereas they pay them better when drugs are furnished with a rather lavish hand. I 14. Patient remarks: "Doctor, you're furnishing lots of medicine." Your reply should be: "I know what you want. understand your case. I prescribe confident that all the medicine will be required." 15. We should reiterate frequently to our pessimistic patients, that it is a sin to look on the dark side of things, and thus the moral nature may turn its energy healthwards. 16. To the child with enlarged glands, give hydroiodic acid, Fowler's solution, calcium hypophosphite and podophyllin, with iron and quinine if required. 17. Wherever suppuration is present, or possible, give calcium sulphide, 1⁄2 grain every half to one hour. 18. If complexion is bad, give alnuin, boldine, and sodium phosphates, the last 3iij or more per day, and locally a solution of bichloride of mercury (1 to 200) mixed in alcohol and water. 19. Possibly, corns are not very far from being a skin rheumatism, for they are usually present in rheumatic patients, and the salicylates locally are of benefit. 20. For sore mouth, H, O2 locally, saline laxative, calcium sulphide, and ichthyol internally and locally. Strychnine arsenate as a tonic, and bovinine as a food. 21. My patient had a good deal of itching around the anus. I suggested that he keep his fingers as clean and aseptic as possible. The itching passed off. 22. Where there is a dirty community towel, there look for sore hands, fingers, and eyes that are stubborn to cure. 23. A well is near some large elm trees, the roots are in the water, those who drink the water are sick. See? 24. Often, a large operation of the bowels will remove a fit of dumps. DR. C. E. BOYNTON. Los Banos, Cal. Another Answer to Query 16. TO THE Medical CounCIL: I wish to offer an answer to question No. 16, by Dr. Proud, in your February issue. If the question was asked by an intelligent member of the family, I would answer candidly; would name the main symptoms, give his pulse-rate and fever record, and then say that those symptoms might be present in any one of several diseases; that the case would be more fully developed soon. If they did not seem to be entirely satisfied, I would say that the names of diseases are sometimes arbitrary, and that the same disease would often greatly vary in its symptoms in different cases. Therefore, judicious physicians often treat the symptoms rather than the name. In my experience of more than forty years in practice, I have several times known physicians to diagnose a case as bilious fever, or as grippe, when, in a day or two, the patient would be unfair enough to break out with the measles. Question 16 is a very important one, and often leads to others about a consultation, or even a change of doctors, unless it is satisfactorily answered. This is my apology for this effusion. New Philadelphia, Ind. Precipitate Ejaculation. To THE MEDICAL Council : This is a trouble that is much more common than is supposed, and which most of our text-books do not even mention. Many complain, especially young men, of precipitate ejaculation. They begin the exercise of their genitals at a premature age, and soon grow to believe that copulation five or six times a week is a part of their existence, and then apply for treatment of the resulting hurried discharge. These irregularities and excesses are most natural under the circumstances. Their victims have been masturbators, patrons of vice and immorality in all forms, have abused and demoralized their sexual organizations, suffered venereal disease, and have developed a desire for novelties; they will rarely indulge their sexual appetite twice with the same woman. All their amusements and associations are opposed to sexual rest, and then they wonder why it is that their sexual appointments are not normal. These patients, as a class, are always very nervous and excitable, and sexual relations are attended with undue excite |