VENESECTION AND LOCAL DEPLETION 79 bag, and cold wet compress. The latter should be used in connection with rubber sheeting or oiled silk, to prevent general wetting of the bed. Poultices may be discarded as offering no advantage over the bag, and the physician need not support superstitious ideas by speaking of pneumonia jackets, etc. As counterirritants, dry cupping, mustard baths, mustard plasters, cantharides plasters, and iodine preparations are useful. Soothing external applications and percutaneous therapeutics are discussed in the dermatological memoranda and other special chapters in this book. VENESECTION AND LOCAL DEPLETION In cardiac and respiratory embarrassment, when compression of the arm below the shoulder produces marked distention of the veins below (forearm and elbow), and when heart drugs fail to stimulate the lagging heart muscle, the unloading of the heart or embarrassed circulation by venesection is indicated. Six to fifteen ounces of blood may be withdrawn. Local depletion by means of scarification and puncture, wet cupping, or leeching is performed in ophthalmic and aural practice for the relief of local hyperæmia or congestion. Leeches will readily attach themselves if the parts are washed in ice cold water and then slightly scarified as for vaccination. After the leech drops off, the bleeding point will continue to bleed if hot cloths are applied. In case of too profuse hæmorrhage, ice cloths and compression may be used. Scarification is sometimes employed in lymphangeitis and erysipelas, followed by a wet antiseptic dressing. Venesection in Children.-This may be indicated in respiratory failure and for the purpose of relieving an embarrassed heart in From one to three ounces of blood may be removed. Venesection in children is not often practised. The Technique of Venesection. The arm is constricted between the shoulder and elbow by means of a silk handkerchief. The region of the bulging median vein is cleansed and made anæsthetic by injecting a 2 per cent cocaine or stovaine solution. After incising the skin the vein is punctured. A firm bichloride compress will stop the bleeding. THE NASOPHARYNGEAL TOILET The nasopharyngeal toilet, as advised by the author in all febrile diseases, consists in the instillation into each nostril, by means of an ordinary teaspoon, of a spoonful of weak salt water morning and evening (at bedtime and on rising) as the children lie on their backs with the nose tilted up and the mouth open. The liquid does not wash through at once; some of it remains in the various recesses of the nasal cavity and is eventually sneezed THE NASOPHARYNGEAL TOILET 81 out or swallowed. In this way putrescible matter and bacteria are washed away. This form of mechanical antisepsis is indicated as follows: It is the best method of local treatment of all cases of diphtheria, in which instances it should be resorted to every two hours; moreover, it is the most satisfac tory local routine treatment in all diseases in which diphtheria frequently sets in as a complication, e. g., in measles, scarlatina, and pertussis; furthermore, it is a necessity before and after amygdalotomy and all operations on the nose and throat. This method is far superior to gargling, and the writer, after an experience of more than fifteen years with this method, again takes pleasure in recommending it on account of its great value and harmlessness. In many forms of reflex cough, also in pneumonia and tuberculosis, it is far superior to nauseating expectorant mixtures, and in all forms of febrile disease in which the nasal secretion becomes dry, crusty, or hardened, half a teaspoonful of salt water instilled into each nostril affords much relief. The nasopharyngeal toilet not only does not provoke middle ear and sinus complications, but apparently prevents them. If chemical antisepsis is in addition urgently demanded, as in malignant sore throat, we may employ a 5 per cent solution of ichthyol in water or a bichloride of mercury spray, 1-10,000. The surface of the nose may be covered with vaseline, and an albolene spray may be used to advantage in some cases when the watery fluid is not soothing enough. See also article on Diphtheria in Pædiatric Section. TONICS IN THE CONVALESCENT STAGE The best general tonic after acute illness is probably a change of air, from the city to the country, from the mountains to the seashore, and vice versa. A regulated digestion and exercise, massage, baths, and restful surroundings are welcome to every convalescent. The administration of dilute hydrochloric acid after meals will aid digestion, and a normal digestion and good food will soon bring the blood composition up to the proper standard. Hydrochloric Acid. R Acidi hydrochlor. dil., Five to ten drops in sugar water after eating. 5jv. A teaspoonful in water after eating. Shake well. 5j; 5j; 3jv. If iron, arsenic, phosphorus, and other drug tonics are to be given, the tongue must first be clean, and should a clean tongue become coated after the administration of drug tonics, the latter should be discontinued and MENTAL THERAPEUTICS AND WORK FOR THE SICK 83 hydrochloric acid substituted. The author uses the following formulæ in his practice for anæmic convalescents: Tinct. ferri. chlorid., in doses of 2 to 20 drops three times a day. R Elixir gentianæ comp.,. Tinct. ferri. chlorid., Dose, to 1 teaspoonful three times a day. 3ij; 3j. Liquor Peptomangan.-Dose, 5 to 15 drops three times a day. Liq. Bromo Mangan.-Dose, 31⁄2 to 3j. Elixir Calisaya Cum Ferro et Strych.-Dose, 3j to 3jv several times. a day. Also the glycerophosphates and hypophosphites of iron and iron tropon. Arsenic is best administered in the shape of Fowler's solution, 1 to 5 drops in water three times a day after eating. Phosphorus in the shape of Thompson's solution may be given to children in 10 to 20 drop doses three times a day in water. Elixir of phosphorus is a palatable preparation. Phosphorus chocolate lozenges may be given to children as candy. Adults take larger quantities. A very good alcoholic malt tonic for convalescents is barley wine, and several of the large brewing companies of our country make a palatable malt beverage containing little or no alcohol. Malt and maltine preparations are beneficial for convalescents. MENTAL THERAPEUTICS AND WORK FOR THE SICK The influence which may be exerted on the minds of the patients is of the utmost importance in acute as well as in chronic ailments. Abnormal mental conditions lead to an exaggeration of symptoms, to imaginary ailments, and to undue apprehension, which interfere (by a general depressing effect upon bodily functions) with the favorable progress of disease. Determination and a strong will are efficacious in resisting and overcoming disease. Lives are made miserable by injudicious injunctions to rest from work or by failing to suggest some congenial work. Old people who are apt to become introspective and a burden to themselves are often made. happier if they go back to nature and spend their declining years in the country, where they can always find some form of pleasant occupation during the day and rest and quiet surroundings at night. In chronic ailments the tactful physician will hold out to the patient the encouraging features of a case, and not "imitate a judicial sentence of death" by telling the patient that he is in no immediate danger and that he may live for several weeks or months. A hopeful attitude toward the patient is always correct and ethical. It prolongs life and alleviates suffering. In conclusion, I wish to emphasize that the important points in the management of acute febrile disease are diet, hydrotherapy, rational stimulation, and free breathing of pure cool air. Drugs no longer dominate our therapeutics. After the bowels have been made to move, drugs are not indicated, unless for some special and substantial reason. The more in |