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Consumption and the Opium Habit.

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My Dear DR. TAYLOR:-The question raised in your journal, whether morphin takers are liable or immune to consumption, has brought out many interesting facts. Dr. Barbour's letter in the January WORLD describes the conditions very clearly, and in his statement that opium masks the symptoms but does not stop the degenerativ features, there is great significance and reality. Recently a study of the causes of death in ten cases of morphin takers showed the following: Acute tuberculosis, 3; pneumonia, 5; and two cases of nephritis. physician who has had very large experience writes me that cerebral hemorrhage has appeared very often in cases under his observation, followed by acute pneumonia, or tuberculosis, with death in a few days or weeks. posed cases of immunity from consumption and other acute inflammations of the lungs by the use of opium is open to question and doubt. That it might occur is certainly possible, the same as exceptions to all rules are found. this fact can only be establisht by a rigid analysis of the symptoms and history of the case. There is one fact about which there can be no doubt that all use of opium lowers the nutritiv functions and lessens the vital powers, both mental and physical, and that the germ of consumption finds most activ soil in low conditions of vitality and nutritiv force.

:

Hartford, Conn.

The sup

T. D. CROTHERS.

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Ergot Treatment of the Opium Habit. Editor MEDICAL WORLD:-It appears that in the current issue of your journal you made some reference to a paper which I read before the New York State Medical Association, in October, on the treatment of drug habits by ergot. I do not know what you said, but it seems to have been enuf to excite inquiry without answering it, with the result that I have been deluged with letters (especially from all

over the South and West), to which I have not been able to reply; and as many of these are pathetically urgent, and as the paper has not yet been publisht, may I beg space in your forthcoming issue for a reply to these queries? Almost the entire number of inquiries has been concerning the treatment of morphin or opium cases; apparently the alcoholics are not as anxious to be relieved.

In treating a morphin or opium habit case, there are two methods which may be pursued: the one, which I prefer, is to discontinue the drug wholly and at once; the other, which the subject would prefer and also, probably, most physicians treating such cases, is to gradually but rapidly discontinue the drug until by the end of the first week the amount given will be so small that it may then be wholly discontinued.

If the drug is immediately and wholly discontinued there must be especial preparation against the reaction, that will begin at from twelve to thirty-six hours after the discontinuance. The use of the ergot should be begun at once, a half dram of the solution injected hypodermically every two hours, or less frequently, according to the quantity of the drug used.

Only fluid nourishment should be given, and that of the most easily digestible character, and not food extracts in alcoholic menstruum. The nourishment should be given every three hours.

In all cases I would give ten grains of blue mass the night before beginning the ergot treatment, followed in the morning by sufficient saline to thoroly clear the bowels, and every night and morning, during treatment, one to two drams of fluid extract of rhamnus frangula should be given so as to secure two or three mushy stools each day.

If the subject is calm at the end of fortyeight hours, the ergot may be given a little less frequently; but it should be continued to the extent of at least two doses a day for a couple of weeks, and at least one for one or two weeks longer.

There are three important helps that should not be neglected in the extremer cases, and they are always valuable. First, galvanization of the sympathetic ganglia, by stroking with hand electrodes from occiput to sacrum, one electrode on each side of the spine, the two separated about four inches. The current should be ten to fifteen milliamperes and continued twenty to thirty minutes, daily or

oftener.

Second, dry cupping, by means of the valve cups exhausted by an air pump, along both sides of the spine and sides of neck.

Third, shock, applied by means of hot and

cold strokings the entire length of the spine. Have a bucket of water as hot as the attendant's hand will bear, and another of cold water or a smoothed lump of ice that can be held in the hand. With subject in sitting posture and back bared, stroke two or three times with a sponge or cloth lightly wrung from the hot water, and follow instantly with as many of the ice or cold water. Repeat these alternations half a dozen times.

This may be employed two or three times a day. All treatment has reference to restoring tone to the circulation, especially in the spinal centers and brain.

The second method only differs in combining during the first week some morphin with one morning and one evening hypodermic of the ergot. If ten grains have been used daily, let the two ergot-morphin hypodermics contain one-half grain morphin each the first day; one-fourth grain each the second day; oneeighth grain each the third day, and so continue lessening each succeeding day 50 percent of the preceding day until the eighth day, then discontinue the morphin.

The solution I commend is Squibb's solid extract of ergot, one dram, dissolved in sterilized distilled water, one ounce; filter the solution and add to the filtered solution two minims of chloroform, gently shaking until it is dissolved. This solution is now made by E. R. Squibb's Sons, and other manufacturers, as Parke, Davis & Co., H. K. Mulford Co., and Sharp & Dohme, make special solutions of ergot for hypodermic use. The difficulty as to making one's own solutions is the matter of thoro sterilization.

Jamestown, N. Y.

ALFRED T. LIVINGSTON.

we

[See pages 534 and 535, December WORLD, for our reference to Dr. Livingston's paper. The above article was received on Christmas day-too late for our January issue, so couldn't publish it earlier than this issue. We hope that this will reach and satisfy all the Doctor's inquirers. Isn't it strange that there are so many opium victims in our country? Every effort of physicians should be put forth, not only to relieve these victims, but to stop making more. A table of say 100, or 500, or 1,000 cases, tabulated, to show the mode of starting the habit, or the cause of starting the habit, would not only be interesting, but it would be useful in showing the dangers to avoid.-ED.]

Editor MEDICAL WORLD:-Please ask the readers of THE WORLD to give their favorit prescription for a hair tonic-one that experience has shown to be reliable. Columbus, Ohio. T. M. LIPPIT.

Thiosinamin in Urethral Stricture.-Nitrate of Silver Injections Over the Pneumogastric Nerve in Phthisis.-Treatment of Opium Habitues.— Mass of Adhered Intestin.

Editor MEDICAL WORLD:-Inclosed please find $2 to apply on my subscription to THE WORLD. I like your journal better the more I see of it. It is very like the good old family doctor, in that it wears or improves with acquaintance.

Blad

And now, Mr. Editor, as I have so often been the beneficiary, I will try to contribute my mite. On page 545 of December WORLD, I find a query from Dr. Diaz, regarding thiosinamin. In an experience of eight years I have employed this drug in one case. My patient was a man of 60 years, and he had suffered a stricture of the urethra for thirty years. der was enormously enlarged and sacculated, and sinuses penetrated the urethra and scrotum in many places. I could only pass a filiform sound, and that only when patient was completely relaxt. As his general health precluded lithotomy at the time, and seeing an article on thiosinamin in Journal American Medical Association at that time, decided to try it. I put the patient on three grains of powder after meals, and in three months he had so far improved as to be able to pass a number ten sound on himself. The sinuses had closed, and the patient's general health had greatly improved, and he was able to pass a fair stream of urin without a catheter. I lost trace of him, and have not had another opportunity to try the drug, but it acted like magic in that one case. To be sure, I used other things as the case demanded; in other words, I treated my patient to the very best of my ability, but something certainly absorbed a large amount of cicatricial tissue, and I have ever given the credit to thiosinamin. One swallow does not make a summer, and one case treated does not fix the status of a drug; and having no similar opportunity to try the drug, I have been reluctant to report this case.

A few years ago I saw an article in your journal upon the curativ effect of nitrate of silver injections over the pneumogastric nerve in phthisis. I have tried it in probably 100 cases since, and failed to find that it did anything save worry my patient. Not the slightest appreciable benefit could be discerned; did not even ameliorate the cough.

I have employed ergot in three morphin cases, by hypodermic injections for a period of five days. Results: Hard work to suppress abscesses from injections, and larger appetite for the morphin. What are we to do in these cases? I have a copy of Dr. Albright's book, and have tried his remedies without the slight

est avail. I have used hyoscin, the most promising drug yet offered, and failed-abandoned it on account of its extreme depressing effects. Now will some kind brother tell me how I am to withdraw the morphin and support my patient? I wonder how many of the profession have witnest the extreme torture the poor wreck is subjected to, when the drug is withdrawn. I have begun the treatment with a brisk calomel purge, followed by salines, and have kept the bowels open with salines; but my last patient, a little delicate woman, persistently refused food for three days-could not force it down her; and when it seemed that death was imminent, I relented and allowed the drug, and she has returned to her regular allowance and is up doing her work. I might add that this patient, a Mexican girl, has been taking the drug for the last eight years. Now will some kind brother enlighten me on this subject? How am I to procure sleep and appetite and otherwise sustain these patients while under treatment? My past bitter experience has led me to believe that the treatment should cover a period of two or three years in these old cases; four or five days would only serve to bring the physician into general disrepute with his patient. I have kept my patients in bed, fed them milk and had them bathed with hot and cold water, as symptoms required, administered all sorts of drugs save opium, and yet I failed. I have about concluded to send my next case to some sanitarium for the treatment of such cases, believing that the country doctor should avoid them.

One more thing and I am done. A short time ago I was called to administer an anesthetic to a patient for appendectomy; operation by a neighboring physician. Upon examination, found a large flat movable mass in right inguinal region; diagnosed matted intestins. Patient was operated upon next day, and my diagnosis was found correct-so much so that abdomen had to be reclosed without removing any part of appendix. The man had had attacks for the last six years, as I afterwards learned. Is there anything to be done when adhesions cannot be judiciously broken up? I mean any procedure whereby patient will become immune from further attacks, and still keep his mass of adhered intestins and appendix. What becomes of such cases?

I am barely out of bed from a severe attack of pneumonia; hence poor writing. WALTER K. CALLAHON, M.D.

Owyhee, Nev. [Doctor, suppose you tell us, from your recent experience, how it feels to have pneumonia. We will leave your questions open for discussion.-ED.]

My Line of Treatment for Pneumonia. Editor MEDICAL WORLD:-Inclosed find check for $3.00 for subscription to THE WORLD. You ask your readers how we will treat our pneumonia cases this winter. We cannot treat all cases alike, but I shall try to give you my line of treatment.

Hygienic.-If possible I have my patient put in a large, well lighted room. I instruct the family or nurse to hang a thermometer in the room and to keep the temperature at about 68° F. I have them keep a dish for expectoration that I may see it, and if they note any decided change in its character to place a piece of white paper over the already expectorated sputum that I may note the change. I have the patient use a bedpan, and do not allow him to get out of bed. I disinfect stools, urin and sputum. I do not allow visitors. Sometimes I instruct the family how to use a clinical thermometer and how to count the pulse and to keep a record of the same. I give my patients plenty of fresh air.

Diet. I have my patients drink plenty of water. I don't feed much the first 48 hours. After that I feed a liquid or semi-solid diet at regular intervals. This usually consists of a glass of good rich milk with a raw egg and a tablespoonful of whiskey; also buttermilk, beef juice, rice, toast, sometimes liquid peptonoids. I feed once in four hours, six times daily. I watch the stools and see that the food I am giving is being digested. I do not overload the stomach, or give food or medicin that nauseates my patient.

Medicinal Treatment: Local.-If seen early, I apply a mustard plaster until surface is well reddened, then sometimes a clay poultice, warm and changed once in 24 hours. I like a cotton jacket. For a local application I use lard and oil of amber, mixt together without heat. If pain is severe I use mustard for counter-irritation, then laudanum and fluid extract of aconite, 6 to 1, warmed; I saturate a cloth in this and apply to side. Change often and cover with a warm poultice.

Internal Treatment.—I always clear the intestinal tract, usually with gr. calomel one or two every 2 hour for 8 to 24 hours, and a heaping teaspoonful dose of sodium phosphate or Epsom salts every four hours; then laxativs, usually sodium phosphate or a c. c. pill to get one or two stools daily. I always examin the abdomen for signs of tympanites and toxic absorption, and if necessary change or withhold diet. I seldom use intestinal antiseptics.

If seen early and the patient is robust and the temperature high, and the pulse full and bounding and we are just getting a congestion of the lung tissue, I give aconite, 10

drops of a good fluid extract in a glass full of water, teaspoonful doses every fifteen minutes until the pulse responds, or five drop doses of Norwood's tr. veratrum every hour. In fully one half of my cases I do not use these remedies at all, and never except in the congestiv stage. This treatment usually covers the first 24 hours. Then I give strychnin, Then I give strychnin, aboutgr. once in four hours, and whiskey in the milk in tablespoonful doses; tepid baths for the high temperature, and if temperature still runs high-102° to 104°-I use five drop doses of a good fluid extract of digitalis in of a glass of water every hour-sometimes more often. If cough is irritable and annoying and the patient nervous, I give five to fifteen drops of fluid extract of camphorated opium once in two to four hours. If the arteries are sclerosed, I use gr. doses of glonin in place of the strychnin. This brings us near the crisis, and now in a case of lobar pneumonia I like to see my patient often-if possible once in four hours, always twice daily. If the heart is doing well I do not change the treatment; if not, I increase the strychnin and give plenty of whiskey-an ounce hourly--sometimes a pint or more in 24 hours. For collapse, whiskey and strychnin hypodermically and ammonia inhalations; oftentimes in place of whiskey by the mouth I give spirits of camphor in hot water, and early hypodermic injections of ether, 15 to 30 m. every 1, 2, 3, or 4 hours.

I seldom give quinin, never the coal tar products, no cough mixtures, occasionally the salicylates if I think there is uric acid. If I can get good leaves I substitute the infusion for the fluid extract of digitalis. I always give plenty of water, and if I think the patient is not drinking enuf I often order a cup of catnip tea to be given with the medicin.

After Treatment-I keep patient in the house for a week, sometimes with no medicin; again, malto yerbene and a preparation of the hypophosphite or iron; often sodium phosphate for ten days or two weeks.

Concerning Results.--Until last winter I thought I was the "whole thing" in treating pneumonia. Prior to then I had treated fiftytwo cases with two deaths. Last winter I treated thirteen cases with four deaths, and these in succession. One was an alcoholic, 52 years old. He lived twenty-four hours. Postmortem revealed fatty degeneration of liver, heart, and kidneys; the right lung was solid and seemed to be drowned, or waterlogged. This man's temperature was not above 101°, but the minute the disease put an extra strain on the heart the pulse got rapid and thready, and heart stimulants did absolutely no good. Another I saw on the second day of the disease; a man 62. He refused to go to bed until the

third day, and when I told him he had pneumonia he laught at me and said he had for years spit up blood when he got a little cold. The sputum was rusty and very tenacious, and at the last it was almost impossible for him to get it from his mouth. He was jaundiced on the fourth day, and there was a foul odor to the perspiration. He died on the sixth day of illness. I tried almost everything except oxygen inhalation and venesection, which the family would not allow. I sometimes think the man would have lived just as long without a physician. The other two cases were 54 and 68 years respectivly; the first had valvular heart trouble, the last a weak intermittent heart. Everything possible was tried and done. Physicians in consultation, trained nurses, normal salt solutions, ether hypodermically. Nothing did good.

The mortality of pneumonia depends entirely upon (1.) The patient, the age, and the heart; a man of 30 may have a heart of 70. (2.) The degree of involvement-one lobe, two lobes, of one or both lungs may be involved, and the greater the area of lung tissue involved the graver the prognosis. (3.) The virulency of the infection. I belive pneumonia, like scarlet fever, may be of different degrees, mild or severe, and that all deaths that occur at or near the crisis are caused by nothing more nor less than a septicemia.

When I read of a physician treating 100 or more cases of lobar pneumonia with none or one or two deaths, I think either he has been very fortunate in having light cases, or that he diagnosed some cases of congestion of lungs or acute bronchitis as pneumonia. Scio, N. Y.

E. W. LAWALL. University of Buffalo, 1897.

Digitalis and Strychnin in Pneumonia. Editor MEDICAL WORLD: Dr. W. C. Cooper says in January WORLD, page 15, "Never whip the overworkt heart with digitalis or strychnin." In answer to this I wish to say, use digitalis and strychnin in pneumonia, as in any other disease, when the symptoms call for their use. No drug should be given simply because the patient has pneumonia, but when indicated by the condition of the patient. H. C. Wood says, in his excellent work on therapeutics: "When in any form of pneumonia the right heart is yielding to the strain of forcing blood thru the pulmonic capillaries prest upon and reduced in their aggregate lumen by exudation, digitalis may be of the utmost service."

Some years ago I read a discussion on the treatment of pneumonia in which one of the speakers said: "Do not harass the heart by the use of digitalis." Dr. H. C. Wood arose to

The Spanish-fly Blister in Pneumonia. Editor MEDICAL WORLD:-Is not Dr. A. K. Van Horne, in the December WORLD, too positiv about the good effects of the fly blister in pneumonia? How does he know that the blister was the "determining cause that enabled many to recover from pneumonia that would have died without it?" How does he know that the "dozens" of cases of pneumonia that were "relieved" by the Spanish-fly blister would not have recovered just as quickly without it? How can a blister, antiphlogistine, or any other application to the skin of the chest, "draw serum from the lungs?" Is not the proposition absurd? There is no direct anatomical connection between the skin of the chest wall and the lungs. Does not the serum brought out by a blister or other application to the chest wall come from the general circulation? Would not the same amount of serum drawn from the bottom of the feet or any other part of the body do just as well? Would not a hydragog cathartic, like epsom salts, accomplish very much more and leave no annoying sore on the skin? Would it not be better still to dilate all the arterioles thruout the body and allow the blood to flow from the congested arterial system into the veins, thus relieving the congestion in the lungs and diminishing the labor of the overworkt heart? This can be accomplisht by the administration of Norwood's tincture of veratrum viride. The best treatment of the first stage of pneumonia, in my opinion, is epsom salts and veratrum in suitable doses, especially in sthenic cases. I have never been able to see what good a blister could do a diseased lung. I may be wrong. I do not "know," as Dr. Van Horne does. I am open to conviction. But bare assertions do not instruct. "Let us give a reason for the faith that is in us." In pleuritis, alone or accompanying pneumonia, a blister might possibly do some good. I am sure that heat, dry or moist, gives much comfort in painful cases.

But heat is transmitted directly thru the chest wall to the seat of pain. It does not have to circulate in the blood and thruout the body to get there. Heat does not act at all like a blister; and the latter should not be compared to the former. L. C. ALLEN, M.D.

Hoschton, Ga.

Pneumonia in Alaska and Michigan.-Cystitis. Editor MEDICAL WORLD:-Having had considerable to do with pneumonia here and in Dawson and Alaska, I should like to endorse a few things already advocated, and emphasize others overlookt. Give veratrum viride in early stages, and calomel, and you will often abort the disease, or prevent it from invading other portions of the lung. Continue calomel in small doses all thru. Give strychnin and whiskey freely. When required, blood letting in well selected cases works well where the disease sets in very severely in a full-blooded, strong, fleshy person, and promises to run a very rapid course. Also when you have exhausted your resources, and your patient is going to shuffle off in a short time, do give him the one chance for his life, and bleed freely. It will relieve the heart and lungs of the engorgement, and your patient will feel better almost immediately; and this will save many of your patients, when everything else has failed. Don't be afraid of it. Antiphlogistine I consider the best external application that can be used, if properly applied.

This line of treatment will save over 90 percent of pneumonia cases. Of course, keep up the strength by good, nourishing diet. Avoid expectorants; they are worse than useless. Have plenty of fresh air and an even temperature thruout, with moisture.

Before closing, I should like to ask your treatment for a case of chronic cystitis of five years' standing. Man, 36 years old, single, no history of specific trouble; suffers severe pain while urinating, but no other time; and the pain is near the end of penis. Passes water every hour or two, day and night. Urin alkalin, with large quantity of mucus and pus. He has been the rounds, and had the bladder washt out, and claims that it always made him worse. He says he feels perfectly well excepting this trouble. He has been under my care only a short time. His family history is good. When he had the first attack, he was laid up for two months, and passed a large quantity of blood. What would you advise, Editor and readers?

Sault Ste. Marie, Mich. T. N. ROGERS. [See yearly index, in December WORLD, and look up the references under the head of cystHas your patient been examined for stone?-ED.]

itis.