the pupil with as little other influence on the eye as possible, as in opacity of the centre of the lens or cornea. For this purpose it may be instilled once in every one, two, or three days. When it is desired to dilate the pupil for a brief period, as for diagnostic purposes, the slowness of the recovery from atropin is a serious objection. It is then better to use Homatropin hydrobromate I part (1 grain). Distilled water 500 parts (one fluid ounce). A single instillation of this will usually be followed by a return of the pupil to normal in twenty-four hours. It however at its maximum effect abolishes entirely the reaction of the pupil to light.

A mydriatic that gives in the dark room the widest possible pupil for ophthalmoscopic examination, and relaxes satisfactorily the contracted pupil of old people is the ordinary solution of cocaine.

Cocaine hydrochlorate 1 part, (2 grains). Distilled water 30 parts, (1 fluid drachm). At the same time it does not abolish the reaction of the pupil to strong light, and therefore causes less inconvenience when the patient is exposed to it; and its action passes off in a few hours, while the power of accommodation remains practically unimpaired.

A single drop of either of the above solutions will suffice, but they are all rather slow in their action, requiring an hour or more to produce the maximum effect. If it be required to dilate the pupil quickly, duboisin sulphate, or hyoscyamin hydrobromate may be used in solutions of the same strength as that of homatropin referred to above. Such a solution will fully dilate the normal pupil in 10 to 20 minutes.

Where dilatation of the pupil is to be secured in the presence of plastic iritis, or other considerable acute inflammation of the eye, very much stronger solutions must be employed, and their instillation repeated as often as possible without causing too violent symptoms of systemic poisoning by the drug. In iritis a good strength isAtropin 1 part (1 grain).

Distilled water 60 parts (1 fluid drachm).

Duboisin and hyoscyamin are probably as effective as atropin, but are to be employed in solutions of half the strength of the atropin, on account of their greater liability to cause constitutional symptoms.

In any case before using any dilator of the pupil the presence, or immanence of glaucoma should be carefully excluded.

PREDOMINANT

AILMENTS AND THEIR TREATMENT AT A LONDON CLINIC.

The London correspondent of the Therapeutic Gazette, describing the rush of patients to St. Bartholomew's Hospital Medical Clinic, states that the nature of the medicines most in favor will give some indication of what is the matter with these applicants for relief.

That which is used in by far the greater number of cases is the " queen iron," mixture, as they call it, a simple mixture containing ferric chloride and quassia, the taste of which leads the patients to think they are taking quinine, hence their name for it. This seems to do a wonderful deal of good in the cases of atonic dyspepsia, struma, general wretchedness, etc., which are engendered by working for long hours in the crowded, hot rooms which so many of them have to frequent. Two or three bottles of this generally suffice to make cases of this sort feel all right again. Perhaps next in favor comes the "haust. menth. sulph. c. mag. sulph ":

small dispensary is made up of cod liver oil, pills, the ever-valuable house physic (dear to the memory of the indulger in excess of alcohol), ointments, etc.

ICE IN THE TREATMENT OF ACUTE PNEUMONIA-A COLLECTIVE

REPORT.*

BY THOMAS J. MAYS, M. D., (J. M. C. 1868). Professor of Diseases of the Chest in the Philadelphia Polyclinic.

Whatever its nature may be, it is quite certain that no other disease has elicited a greater number of conflicting opinions concerning its treatment than has croupous pneumonia. Forty years ago bleeding and blistering were regarded as its specifics; but these are now, and for the last twenty years have been, scarcely thought of in this connection. In the meantime hot poultices, aconite, veratrum viride, digitalis, quinine, etc., took their places; yet it is not too much to say that these have all led to disappointment and have come to grief in the retort of clinical experience, and that finally the profession has gravitated to the conviction that the disease is self-limited in duration, and that hence all efforts to control its course are fruitless, if not actually harmful.

To be thus compelled to stand before a disease and acknowledge our helplessness and impotency is, to say the least, an unenviable position, but I must confess that until I became familiar with the value of local cold applications in pneumonia I was in entire accord with this idea. Since then I may say that I am able to approach a case of pneumonia with a greater degree of assurancenot with the feeling, however, that we possess a specific, but with the confidence that we have in cold an agency with which we are able to impress and circumvent the severity of the pneumonic process. I believe that cold properly applied will affect the death-rate of pneumonia as profoundly as it has affected that of typhoid fever, and, although I do not expect a rapid introduction of this measure, on account of a deep-rooted prejudice which

*Medical News.

exists against the use of cold in almost all internal diseases, I trust that the evidence which is herewith submitted will serve to commend it to the serious attention of the profession.

Under the titles "Can Croupous Pneumonia. be Aborted?" and "Ice in the Treatment of Croupous Pneumonia," I contributed two papers to The Medical News of September 24, 1892, and January 21, 1893, respectively, in which are related three cases of pneumonia that were treated principally with applications of ice to the chest. After the appearance of the first paper I instituted a collective investigation on a small scale by sending a number of circulars to various members of the profession, inviting a trial of the ice-treatment, and as a result of this inquiry I submit the following abstracts of cases which have been kindly returned to me, and also of those of other cases which I have collected from the literature on the subject. (The details of cases are necessarily omitted).

*

The histories of these fifty cases open up many points of interest in the discussion of the influence of ice in the treatment of acute pneumonia, and as pertinent to this subject I will append the following comments:

1. The resolving power of ice on the exudation. This is a marked feature in its therapeutic action, and must be regarded as one of the strongest factors in its curvative influence. This can at least be partly explained on the following basis: The most apparent lesion in croupous pneumonia is an enormous distention of the pulmonary capillaries, with partial or complete stasis of the blood in these vessels, exudation of the fluid constituents of the blood, and diapedesis of white and red bloodcells into the alveoli of the lung. It is well known that cold has the power of contracting the blood-vessels, and from this action one can understand why it should exert a beneficial action in pneumonia, by giving tone to the capillaries, by restoring the normal bloodflow, and thus checking the leakage. But there is often reason for believing that it also

*Similar circulars will be cheerfully sent by the author to any one who may apply for them.

dissolves the exudate in the pulmonary alveoli. For example, there may be a pneumonic area in which there is absence of respiratory murmur, with the presence of a flat percussionnote and bronchial breathing-indicating, beyond doubt, that the process has passed beyond the stage of engorgement and into. that in which the exudation has taken place into the alveoli; yet the application of ice will, in a remarkably short time, develop a new group of physical signs, such as crepitation, reappearance of the respiratory murmur, diminution of flatness, etc., indicating that a break-down occurred in the exudation. This has not only been observed by myself, but is dwelt on by Dr. Lees, who says: "In many cases I noticed a striking arrest in the development of the physical signs," and that the icebag "distinctly tends to repress the inflammatory process in the lung."

Influence on symptoms. No less decided is the influence of the ice on some of the most prominent symptoms of pneumonia. The pain, difficult respiration, cough, and expectoration, are remarkably relieved, and the temperature is frequently depressed two or three degrees in the course of half a day. The beneficial influence exerted on these symptoms produces a very agreeable effect, and often makes the ice acceptable to those who, at first, protest against its use. This I have noticed in most of my cases, and it has also been witnessed by others, as will be seen by the histories of the cases that have been reported to me.

Is the ice injurious? My own rather limited experience with the ice-treatment does not show that it is accompanied or followed by any evil consequences, nor have any of those who have reported cases to me observed any such results, although some of them kept the ice applied for two weeks. Dr. Lees says: 'I have never seen any harm follow from the employment of the ice-bag in pneumonia."

Ages of patients. It is important to note in this collection that the ages of the patients in whose cases the ice was applied varied from infancy to old age-the youngest being six and a half months old, and the three oldest

sixty, sixty-five, and seventy-four years respectively.

The results. It may be said, without claiming too much, that the results obtained from the ice-treatment of pneumonia have been good. Out of the fifty cases which I collected but two were fatal, making a death-rate of 4 per cent. In estimating this mortality-rate it must be remembered that at least one of the cases that died was an exceedingly unpromising one, being a sufferer from chronic leadpoisoning, and also very intemperate; while the pneumonia which caused the death of the other one was in all probability an acute exacerbation of an old attack. In Dr. Lees's series of eighteen cases no deaths occurred, nor did any occur in the eleven cases reported by Dr. Jackson. Moreover, the Lancet, of August 10, 1892, refers to an article by Dr. Fieandt, published in Duodecim, a Finnish medical journal (an original copy of which I am unable to secure), in which there is an account of 106 cases of pneumonia treated with iceapplications by that gentleman, and notwithstanding that among these there were ten cases of double pneumonia, and that the epidemic of the disease was rather severe, he had only three deaths, or a death-rate of 2.82 per cent. Adding these cases to those reported in my collection, we have a total of 156 cases of pneumonia treated by means of cold applications to the chest, with five deaths, or a death-rate of 3.20 per cent.

While the number of cases reported here is not very large, it is nevertheless evident that the results of the ice-treatment are much superior to any other with which I am familiar. Thus, according to Osler, the mortality-rate of 1012 cases in the Montreal General Hospital was 20 per cent., while in the Charity Hospital at New Orleans it was 20.01 per cent. Of 1000 cases of pneumonia treated in the Massachusetts General Hospital, from 1822 to 1889, the mortality was 25 per cent. In Dr. Hartshorne's valuable paper on " Pneumonia" it is estimated that the death-rate from this disease in the Pennsylvania Hospital during the years 1884, 1885, and 1886, was a little more than 31 per cent. In comparing the

results of the ice-treatment, so far as they go, with those which have been obtained from the treatment pursued in the hospitals named, we find that the former are about eight times better than the latter. It will be of great interest to see by future clinical investigation whether these satisfactory results can be maintained, and if this can be done even approximately, it is needless to say that a pronounced advance in the therapeutics of acute pneumonia has been made.

THE TREATMENT OF ACUTE
GONORRHEA.*

BY JOHN V. SHOEMAKER, A. M., M. D. Extract from Clinical Lecture at the Medico-Chirurgical Hospital, Philadelphia.

The treatment of acute gonorrhea embraces both constitutional and local measures. As regards the former much depends upon a proper regulation of the diet and habits of life. At the onset of the attack the patient should, whenever practicable, be directed to keep the recumbent posture for a few days. This alone has much to do with diminishing the severity or abridging the cause of the disease. I must confess, however, that it is but seldom that patients are able or willing to confine themselves to the house, much less the lounge. The patient should be directed to abstain from meat, condiments, spices, salty, greasy or fried foods, tea, coffee, malt liquors, wines or spirits. Asparagus, cheese, tomatoes, strawberries and pastry are also to be prohibited. He should live upon milk and farinaceous food. If he is obliged to go out on business he must, at least, avoid much walking or standing. A jolting ride, above all, horseback exercise, is extremely injurious. Female society should be carefully avoided. The penis and scrotum should be supported by means of a suspensory bandage. Arrangements should be made for catching the discharge, but no dressing should be adopted which keeps the penis too warm, as heat favors the continued turgescence of the organ. Neither should the penis be constricted by a tape or bandage.

* Medical Review, June 24.

Pledgets of borated absorbent cotton answer a very good purpose when the foreskin is long enough to retain them in position. When the glans is uncovered a sock or a soft muslin bag may be drawn over the penis and fastened to the under-clothing. Both for the sake of cleanliness and because it relieves inflammatory congestion the penis should be frequently bathed in water as hot as can be tolerated. I mean bathed by immersion of the entire organ in a vessel of hot water. The liquid may be unmedicated or it may contain common salt, boric acid, Labaraque's solution, carbolic acid, bichloride of mercury or other disinfectants. The ardor urinæ, or pain on passing water, is often notably relieved when the patient micturates into a vessel full of hot water.

The cases before us are all recent. The symptoms have only been present for a few days and none of the patients have as yet had any treatment. Under these circumstances it is well to begin medicinal treatment by the administration of a saline purgative, such as the citrate of magnesia, the Rochelle or Epsom salt.

When the matter of expense is no object the effect of the laxative may be gently maintained by the use of Appollinaris or Vichy water. After the bowels have been well opened it is a good practice to give remedies calculated to dilute and alkalinize the urine. For our first patient, who has a long prepuce, swollen penis and chordee, I shall prescribe:

Tinct. aconiti radicis, gtt.xvj
Spir. etheris nitrosi,
Potassii bicarbonatis,

3

M.

Syrupi acaciæ, q. s. ad f3iv. Et. ft. sol. SIG.-Tablespoonful in water every third hour.

The salts of potassium render the urine. alkaline. The bicarbonate, in conjunction with small doses of sweet spirit of nitre, increase its quantity while the bromide obviates the tendency to chordee. The aconite is of value in reducing swelling, more especially of the prepuce. The fluid extract of belladonna answers the same purpose and may be substituted in one-half minim doses for the

The

aconite in the foregoing prescription. second man may be placed upon the same mixture minus the aconite. The third patient, on account of the severe pain which he suffers, shall take one-eighth grain of morphine sulphate in the same mixture instead of the aconite. Patient number four needs only the bromide and the bicarbonate of potassium with the sweet spirit of nitre. If the chordee is not controlled by the bromide an effectual remedy consists in the introduction every night of a suppository containing one-half grain of powdered opium and two or three grains of pulverized camphor. A simple method, which often reduces chordee, is to surround the penis with a towel wrung out of cold water. When painful erections are persistent the abstraction of eight or ten ounces of blood from the perineum by means of leeches will overcome the difficulty.

After the above treatment has been continued for several days and the severity of the disease has somewhat abated we may advantageously resort to those drugs which, elimated in the urine, exert a beneficial and presumably antiseptic influence upon the urethra. Among such remedies copaiba, cubeb and oil of sandal-wood have long been esteemed. More recently salol and kavakava have been added to our list of resources. Copaiba may be given in the dose of ten grains to one-half or even one drachm. It is apt to disorder the stomach when long administered. It is advisable to begin with small doses and gradually increase. Copaiba may be prescribed in conjunction with liquor potassæ and sweet spirit of nitre and, if deemed necessary, small doses of morphine. Copaiba is often also ordered in combination with oil of cubeb, the dose of which ranges from five to ten minims. Cubeb is likewise liable to disturb digestion. The oil of sandal-wood is given in five-minim doses, one, two or three times a day, dropped upon sugar or enclosed in capsules. Kava-kava is exhibited in the form of fluid extract, the dose of which is from fifteen minims to onehalf drachm. It is efficacious and better borne than either cubeb or copaiba. Salol

is administered in three to five-grain doses four, five or six times a day. It is split up within the body into carbolic and salicylic acids which disinfect the urethra as they are eliminated in the urine. Salol may be combined with cubeb and copaiba.

The

The local treatment of acute gonorrhea consists, in addition to cleanliness, in the use of injections. If these are too strong, or are begun too early, they aggravate instead of relieving the symptoms. It is well, therefore, to caution the patient that if the injection. produces decided smarting, the fluid should be weakened by the addition of water. injection should be performed slowly and the liquid allowed within the urethra for two or three minutes. We have many substances which make suitable injections. Among the most useful may be named the acetate of lead, sulphate of zinc, tannic acid, or vegetable preparations containing tannic acid, subnitrate of bismuth, corrosive sublimate, peroxide of hydrogen, etc. Combinations which I often use with advantage are:

Many other efficient formulæ can be found. The hour, however, has so nearly expired that I shall have time to say but a few words concerning the treatment of the chief complication. Balano-posthitis is relieved by the injection of simple or medicated water beneath the foreskin. If phimosis occur continue the injections and envelope the penis in lead water and laudanum. If this will not relieve the difficulty split up the foreskin along the dorsum. Paraphimosis is to be reduced by compressing the glans with the thumbs and drawing the prepuce forward with the index and middle fingers. Abscesses are opened. Buboes will generally retrocede under the influence of iodine and pressure.