The first step in an attempted diagnosis is to exclude those diseases which more or less closely simulate poisoning in their symptoms. Of those simulating irritant poisons, the most common are cholera, cholera morbus, acute indigestion, ulceration of the stomach, acute gastritis, gastro-enteritis, peritonitis, appendicitis, hepatic or renal colic, and intestinal obstruction in later stages. Those which resemble poisoning by narcotics include hysteria, cerebral hemorrhage and thrombosis, epilepsy, convulsions due to organic cerebral lesion, tetanus, cerebritis, meningitis, uremia, and organic heart disease. It is always well to take a comprehensiv survey of the surroundings of the patient while striving to interpret the symptoms. A partially emptied bottle, or the odor of one completely emptied, with or without a label, accompanied by the odor of the breath of the victim or the marks of corrosion on the lips, tongue, or throat, would often make certain a diagnosis of poisoning by carbolic acid; chloroform and the crude opium preparations are also often recognizable. The vomited matter and the feces should always be subjected to careful scrutiny; the odor of carbolic acid, of potassium cyanide, and of laudanum are easily distinguishable; phosphorus is luminous in the dark; and in arsenical poisoning one may often detect the insoluble erystals of the trioxid of arsenic.

The following rules are safe to follow in almost all instances: (1) In cases of poisoning the symptoms appear suddenly, and often in one seemingly in perfect health. (2) The symptoms frequently arise soon after ingestion of food, drink, or medicin. (3) If several persons have partaken of the same food or drink, they generally develop the same symp

toms.

Disease, with few exceptions, is preceded by a variable period of indisposition and does not attack with the impetuosity of poisons. It must be remembered, however, that in some cases of poisoning, there is an unaccountable delay in the development of the symptoms; and the time of development is always influenced by the condition of the stomach as to the presence of food, and the form in which the poison has been ingested.

The difficulties surrounding a diagnosis are augmented in cases of chronic poisoning where the doses are small and frequently repeated, or where poison is ingested during the course of any disease. Sudden and severe illness following soon after taking food, drink, or presumably properly prepared medicin, is always suspicious. In such cases, when possible, always subject the suspected food or drink to a rigid examination as to odor, taste, abnormal color, or altered appearance; and place a quantity of

it away where it will be secure from contamination or manipulation until there is time for a complete examination. When several persons who have partaken of the same food or drink simultaneously develop the same line of symptoms, the suspicion of poisoning should be aroused; yet it must be remembered that only one of such a party may be affected because only his portion has been tampered with, or because the others may have a greater tolerance for the drug. The ideal diagnosis would be based upon a chemical examination of the suspected food or drink, yet it is only in the rarest of instances that this is practical. For three drugs, however, we have a test which is speedy, easy to perform, and reliable; and every practician should be able to perform Reinsth's test for arsenic, mercury, or antimony.

Certain routine methods are advisable in the treatment of poisoning, whether or not the agent can be definitly ascertained, and the indications are: (1) The removal of the poison from the stomach. (2) The administration of antidotes. (3) The elimination of the poison as speedily as possible. (4) Counteracting the constitutional effects of the poison and stimulating the system.

Any

The poison is removed from the stomach by inducing vomiting, or by the use of the stomach pump or tube. In many instances vomiting is one of the symptoms, and it merely needs encouragement by administration of tepid water. The emetic is a useful adjuvant to any plan of treatment, and the most convenient form is usually common ground mustard stirred in tepid water; the one-tenth grain of apomorphin hypodermically, or fifteen or twenty grains of sulfate of zinc or copper are useful if at hand. antidote selected may be given in warm water. The stomach pump is seldom at hand when needed, but a very serviceable one is improvised by a piece of rubber tubing of sufficient length, and a funnel. A pint of water should be used at a time, and at least five washings should be employed; it is generally advisable to add the antidote to the water used thru the tube, as a certain amount is retained and will aid in counteracting the effects of the poison. In undoubted cases of poisoning by strong corrosiv poisons, it is not judicious to force or encourage violent retching lest perforation thru the thinner walls of the stomach or esophagus result; in such cases it is better to rely on the antidote combined with copious draughts of water or milk. (Hemmeter, however, differs from other authorities on this feature, and advises the use of the tube in such cases, claiming that, "As such cases run great danger of a corrosiv perforation we have personally used the tube, and let the patient take his chances,

which were better in these cases than in those where the tube was not used.")

Antidotes may be classed as (1) chemical, and (2) mechanical. The mechanical antidote acts by coating the poison or the stomach wall with some insoluble material so as to delay absorption; the class is represented by milk, whites of eggs, fats or oils of any kind, and powdered charcoal. The latter acts by absorbing the poison. Fats, oils and milk are contraindicated in phosphorus poisoning, since they but make the poison more soluble and hasten instead of retarding absorption. The proper chemical antidote for the various poisons may be found in tables publisht in all books of reference, yet it is important to remember the fact, that the compounds formed by the various antidotes are but relativly harmless, and must themselves be removed from the stomach as soon as the immediate danger is over. It is always well in selecting a chemical antidote to choose one which in itself has as little power of harm as possible; for instance, when an acid is indicated to counteract an alkali, select some harmless substance like vinegar or lemon juice.

Never place reliance in the fact that the vomiting has been profuse, but wash out the stomach or employ the antidote; cases are recorded where vomiting had continued for many hours, yet the autopsy revealed enuf of the poison clinging to the gastric walls to cause death. In cases of doubt, the "universal" antidote may be employed. It is prepared by adding two parts of powdered charcoal to one part each of tannic acid and magnesia, and administering in heaping teaspoonful doses stirred in water, and frequently repeated. The physiologic antidotes are occasionally useful, but too much reliance should not be placed upon them, for their use may add to existing prostration, or in other untoward manner.

The physiologic antagonisms of certain drugs are well known; such as atropin to pilocarpin; strychnin to nitcotin; digitalis to aconite; caffein to morphin; chloral to strychnin; etc.; and they may be employed against each other.

Claude Bernard has shown that if elimination and absorption are kept fairly equal, harmful results do not accrue, or are reduced to the minimum. The kidneys, skin, and bowels are the emunctories chiefly concerned in the elimination of poisons, and all should be stimulated to their highest activity. The systemic effects must be well considered; anodynes must be employed to subdue pain; strychnin, nitroglycerin, and digitalis employed against danger of heart failure; and artificial respiration in event of failure of respiration. Oxygen, when available, is valuable in combating in

sufficient oxygenation of the blood; chloral and chloroform are useful in convulsions. Excitement caused by too many visitors is best avoided, and the patient kept quiet in bed. If there is markt coolness of the surface, artificial heat should be employed. The indication for stimulants is easily recognized. in short, the treatment must be symptomatic, and the patient carefully watcht.

Beware of Catarrh Cures.

It is well known that many secret catarrh cures contain cocain. The object is to get the patient in the habit of taking the catarrh snuff, with every prospect that he will continue it indefinitly. Other secret nostrums advertised to cure catarrh, asthma, hay fever, bronchitis, consumption, etc., to be taken internally, are launched on the same basis, and for the same purpose. Inducements are made to take a full month's treatment," and then instructions are given how to order, and the victim is told that the goods will bear no external marks. The reasons are obvious; the plan is transparent to those who will open their eyes. Doctors should explain this to the laity whenever occasion offers. If we had a law like that of Germany, requiring the formula on every bottle or package, the ignorant could not so easily be entrapt into the slavery of drug habits. That such should exist in this “land of the free" is an outrage.

Electrical Equipment for the General Practician.

For some time past we have intended speaking editorially regarding this matter, but communities differ so widely, circumstances of practise and finances are so variable, and above all, the personal element of the operator enters so largely into the case, that it is very hard to write so that all may derive the greatest instruction. While we do not know what electricity is, and while we do not at all understand how it produces results, or what its limitations may be, there is nothing complicated or mysterious about its workings or its management as applied in medicin and surgery. Any man competent to practise medicin, may learn how to handle electricity therapeutically and successfully. It cannot be learned in a moment, any more than one can become a competent anatomist from reading a quiz book; it requires study, just like anything else. There are now books* on

*The Röntgen Ray in Therapeutics and Diagnosis, publisht by W. B. Saunders & Co., Philadelphia, New York and London, 1903, at $4.50. Electricity in Medicin and Surgery, publisht by Boericke & Runion Co., New York, N. Y., 1901. Price, $3.50. Static Electricity and the Uses of the Röntgen Ray: Snow. Publisht by A. L. Chatterton & Co., New York, N. Y., 1903. Price $3.

Electrotherapeutic Guide; Howe & Bennett. Publisht by National College of Electrotherapeutics, Lima, Ohio, 1901. Price $1. Induction Coils; Morrie. Publisht by Spohn & Chamberlain, New York, N. Y., 1901. Price $1.

the market which will induct the beginner from the simplest elementals thru to the more complicated mechanisms and treatments, and tell one all that is known of the matter.

66

If a practician is situated in a reasonably populous community, and power current is conveniently obtainable, any general practician can become a competent manipulator of electricity, and can ethically and legitimately employ the agent in his everyday work with benefit to his patients and with profit to himself. If the practician be in a remote locality, and must depend on the static machine alone, his field will be greatly limited and his results correspondingly unsatisfactory, on the one hand, and disappointing on the other. However, good work is possible with the static machine, to a limited degree, and many country practicians are making money and doing their patients good with no other equipment. The great trouble with the average general practician and the static machine is, that the machine is bought by a man who knows as little of electricity as he does of submarine navigation. He buys the machine, studies it until he can direct the sparks, and "is then ready to apply the healing power of electricity to all comers." Truly, fools rush in where angels fear to tread." Such a man will make a failure, and ever afterwards condemn electricity as useless, or declare its employment a passing fad; and he "knows, because he has tried it" (?). A man who purchases the proper books, and studies them till he thoroly understands them; who then purchases a static machine suited to his needs, and who then studies it till he can operate it intelligently; who will then study the books which teach the proper method of applying a certain method for a certain complaint (provided he has the ability to, and has previously properly diagnosed such complaint); and who only then allows his patients to know that he has the machine and he has the ability to apply electricity as well as it can be applied anywhere-such a man will make a success therapeutically and financially, so long as he does not allow his enthusiasm to run away with his judgment, and begin declaring electricity a panacea for all ills, as too many of the city experts are doing. Such a man would make a success anywhere. But the man who buys a static machine principally for the "moral effect" (?) it will have on those who see it in his office, and who has not the time nor the intention of studying it until he knows something about it, is merely practising the methods of the quacks who prey upon the credulity of the laity; and while he may get a few ill-gotten dollars, they will be few, and he will probably "lose money on his machine."

As to the more complicated methods of elec

trical treatment: The Finsen light, the electric light bath, the violet ray, etc., we advise all general practicians against attempting anything with them. The outlay is too great, and the technic too difficult; the returns will not be commensurate, because the expense of operating will be so heavy.

Radiography is quite a different matter. It is possible to get good fluoroscopic images by means of the static machine, and a few ex perienced operators have succeeded in making excellent radiographs with the influence. machine and suitable tubes and plates. This is, however, the exception; since radiography in itself is a separate study and demands special skill and experience if one expects to do creditable work. We would not advise any practician attempting to do radiographic work with a static machine alone, except for amusement or pastime. While the static machine will make fairly good plates of such small parts as the hand, it fails to do good execution in the hands of the amateur in the very place where assistance is most earnestly desired: In searching for stone in bladder, ureter, or kidney; in examination of the heart; in study of the lungs, etc.

In partial fractures, or in fractures without displacement, the fluoroscope frequently fails to give an image of anything like the actual conditions; while the radiograph, properly taken, will generally detect any fracture. Small foreign bodies are frequently overlookt when depending on the fluoroscope, while easily visible on a good radiograph. There are a few advantages in the use of the static machine for radiographic work to balance the host of disadvantages. On account of the steadiness of its discharge there is less heating of the target than when the induction coil is employed. Hence lighter and cheaper tubes may be employed, and their deterioration is much less rapid than when subjected to the heavy impact from the coil. Since the cost of the tubes is a big item in running an X-ray equipment, this consideration should not be lost sight of. The two models of static machines most used are the Holtz and the Toepler-Holtz; the former is preferable for therapeutic work because its discharge is steadier, its sparks longer, and its effect less painful; for X-ray work there is little difference in the two types.

All static machines are easily influenced by climatic conditions and atmospheric change. One must have a suitable place to keep a machine, and take as good care of it as one would of a piano, if he expects it to work properly when he wants to use it. Very few doctors' offices in the country have a suitable place in which to stand a static machine, or to protect it when placed.

We believe if a practician will study the subject in the books referred to, and give the subject the attention it demands after he has arranged for a suitable static machine and a place to keep it, that he can run such a machine with benefit to patient and doctor. But we do not believe that any general practician will find it profitable in a financial way to go beyond this; he may own a few Crookes' tubes and radiographic plates, and may do minor work for amusement of himself and patients, but he should never base a diagnosis in an important case upon fluoroscopic examination or radiograph made by himself with the static machine. In all large cities, now, there are men who are devoting their attention exclusivly to this work. They have several varieties of the static machine; they have large and perfect induction coils; they have unlimited current at hand and means of modifying it; they have the genuin Finsen apparatus; they have the scientifically constructed violet ray apparatus, and bath cabinets; they have had extensiv and costly experience; and they usually have sufficient funds to back up the heavy drain on their finances. The general practician would better leave the advanced work to such men, and remain content with his static machine, if he has one, or study the matter carefully before investing.*

The Use and the Abuse of Digitalis. Probably digitalis is one of our most valuable drugs; certain it is that when it is indicated, no other can take its place in a manner approximating the effect produced by digitalis itself. It is certain that no drug has been more thoroly studied, and it is equally sure that every teacher of therapeutics takes special pains to instruct his students regarding the benefits to be derived from the proper use of the drug and the specific indications for its use. Yet, notwithstanding, the drug is sorely abused; many practicians, indeed, acting on the theory that "digitalis is a good heart stimulant,' give it in every case of functional or organic heart trouble, whether indicated or not. Some order it because they do not know what else to give, but many more because they do not know the drug. Of all drugs with which the practician should be perfectly familiar, digitalis easily stands high in the list. It is quite as important to know the conditions calling for digitalis as it is to know the drug in its myriad effects.

Digitalis has three great effects: (1) It is a powerful cardiac stimulant; (2) it slows a rapid heart and regulates its rhythm; (3) it acts as a diuretic.

This editorial was written in response to an inquiry. Later we will consider the use of faradic and galvanic batteries.

In simple dilatation, digitalis prolongs the diastole and thus allows the heart a short rest while the ventricles are being completely filled; it strengthens the systole, and thus aids in the complete emptying of the organ. In chronic valvular disease with waning compensation, as manifested by dropsy, deficient urination, and a weak, irregular and rapid heart, digitalis is indicated; but it must not be used indiscriminately in such cases, for if the hypertrophy exceed the dilatation as proven by arterial hyperemia, the drug will work injury. In mitral regurgitation digitalis aids in securing a more complete closure of the valves and aids the right ventricle in its struggle against the resistance in the pulmonary circulation. In mitral stenosis it should never be used except when the right ventricle cannot keep up its work, and anuria and dropsy are present. In aortic stenosis it is only indicated when dropsy coexists with evidence of back pressure in the lungs. Even in aortic regurgitation digitalis is not always contraindicated. While it is true that the prolonged diastole which it induces admits of a longer time for the back flow, it is also true that this is often more than balanced by the more forceful contractions of the ventricle induced by the drug. In such cases with a weak, rapid and irregular pulse, digitalis is deserving a trial. In advanced fatty degeneration digitalis generally proves disappointing, and it should seldom be employed if there has been angina pectoris. In pneumonia, with a failing right ventricle due to inability to drive the blood thru a partially consolidated lung, digitalis often causes markt improvement in the symptoms.

In exophthalmic goitre, digitalis will slow the pulse rate and soothe the tumultuously acting heart; but it is frequently badly borne. In nervous palpitation and paroxysmal tachycardia it is useless, but in the "simply irritable" heart and in arythmia consequent upon simple dilatation, it is frequently of service.

It is the best diuretic we have in dropsy due to heart and kidney disease, and it shows its best results when the pulse is soft and rapid. In dropsy due to liver disease it is a failure, and it seldom produces results in pleural effusions.

Given a sharp clear-cut diagnosis, digitalis will seldom prove disappointing when used only where indicated.

ORIGINAL COMMUNICATIONS

Short articles of practical help to the profession are solicited for this department.

Articles accepted must be contributed to this journal only. The editors are not responsible for views expressed by contributors. Copy must be received on or before the twelfth of the month, for publication in the issue for the next month. We decline responsibility for the safety of unused manuscript. It can usually be returned if request and postage for return are received with manuscript; but we cannot agree to always do so. Certainly it is excellent discipline for an author to feel that he must

say all he has to say in the fewest possible words, or his reader is sure to skip them; and in the plainest possible words, or his reader will certainly misunderstand them. Generally, also, a downright fact may be told in a plain way; and we want downright facts at present more than anything else.-RUSKIN. COMPARE RECORD

READ

REFLECT

I have them made 10,000 at a time, which will last me from twelve to fifteen months. They at first cost me $8 per 10,000, delivered, but I now get them made by another house equally reliable for $5.50. The drugs of course are furnisht by the manufacturers, and are guaranteed to be of the best quality. This makes them cost me from 55 cents to 80 cents per thousand, which is much less than your quotations on page 138, April WORLD.

Then I make up the same combination in powder as follows:

bed with fever at 104°, pulse 120, tongue heavily coated, foul breath, constipated bowels, and every joint from and including the elbow and knee joints of both upper and lower limbs down to and including the fingers and toes, swollen, tender, and so painful that he was crying with distress. I pronounced it inflammatory rheumatism, and expected a couple weeks' sickness.

I immediately gave him a ten-grain dose of the above compound (I call it "analgesine "), and directed it to be repeated every four hours. Directed a five-grain dose of calomel to be given in one hour, and a dose of salts in morning if needed. On calling the next afternoon I found him comfortably seated by the fire, temperature and pulse normal, tongue nearly clean, the swelling, tenderness, and pain all gone. He had even drest and walkt out in the yard. On inquiry, I learned that he had taken the calomel at 8 o'clock, and the second dose of the analgesine at 10 o'clock that night, but not a dose afterward. after taking the first dose he began to feel easier, and sweat profusely for several hours. The bowels acted freely soon after midnight, then he went to sleep and slept until late next morning, waking free from pain and feeling so well that he took no more medicin. Now, did these three doses of medicin cure him of inflammatory rheumatism? or, did he just get well? I have often wondered which.

Soon

Alexandria, Ohio. L. C. LAYCOCK, M.D.

[We are glad that our early seed fell on such good soil as Dr. Laycock. We have often wondered why it didn't find a ready soil in every part of the country. We fully expected that it would, and the only wonder is that every doctor in activ practise did not do as Dr. Laycock did. This and other similar formulas have appeared from time to time, for the benefit of those who were still asleep to the financial interests of themselves and their patrons, but some are asleep even yet, unless March and April WORLDS wakened them up. -ED.]

Editor MEDICAL WORLD:-Referring to articles in WORLD for March and April, will say that a number of years ago I took from a medical publication the following as the formula for antikamnia, said to have originated with Dr. Brodnax, of Brodnax, La.: