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Louis, Mo., who in reply telegraphed back suggesting, in addition to what I was doing, the use of amyl nitrate of one-drop dose by inhalation. This was commenced the following day (February 21 ), and took the place of the ether. The patient had already noticed that he could recognize a flash of gas-light when suddenly turned on directly in front of him. This morning an examination of the fundus of the eye showed about the same condition as at the first examination, except that the disc had a more bluish cast, with a greenish crescent on the temporal side of each. The retina was still anæmic, the veins greatly engorged and tortuous. The morning of the 23d the patient began to make out the outlines of luminous objects. The objects, he said, would seem to partially appear for a second, and then would gradually fade away and all would be dark again. Could count fingers if before a bright light, and discern the openings between the slats of the window-shutters. The eserine was continued once or twice a day; amyl nitrate once an hour during the day, and the patient still kept in the recumbent position with his eyes closed and bandaged. On the following day (February 24) he could recognize his friends, though it seemed to him that he was looking through a veritable London fog.
Examination of the fundus reveals much the some condition as the last examination, viz.: the veins still remaining tortuous, engorged, with sluggish circulation; the retina being pale and swollen, with the bluishgray color. To-day February 28) Mr. Childs could see to make out the headings of newspaper articles, but everything appears as in cameo. All flat objects, as pictures upon the wall, seem to stand out thick and solid; everything, he says, has an appearance similar to objects seen in a dark well or cave, dimly lit up by a single feeble light. Objects directly in front of him gradually come out plainer as he continued to look at them, while surrounding ones slowly fade away. March 1.
Objects come out plainer, but still continue to waver, or come and go. To-day the retina has regained, to some extent, its normal color, yet it is still blanched and the disc is especially anæmic. March 2.
Patient speaks of the sight being better at the close of the day than in the morning, but yet the eyes are not sensitive to bright light. He is able to stare at the bright gas-light without being dazzled, and as he looks out on the street this morning. ( a very bright, sunshining morning), everything appears as though seen through a dark smoked glass. He thinks that the surrounding objects come our as well as those directly in front, or in other words, he thinks that his field of vision is not contracted; but everything appears hazy, or as by moonlight or twilight. The pupils continue to dilate if the myotic is not used at least once a day, and the tension of the globes is above the normal.
He can see, with an effort, to read ordinary newspaper print but as though he were reading by twilight. Speaks of the buzzing of the quinine still in his head, and says that the effect is not yet gone.
March 8. The vision is no better than on the visit of the 4th, and about the only difference is that the eyes are a little more sensitive to light. In order to see to read a flood of light is necessary, and even then it seems as though he were reading by twilight. It seems to be the experience of the best authorities that although in some cases quinine amaurosis dooms the unfortunate subject to complete and irremediable blindness, yet many recover central vision with more or less contraction of the peripheral field.
The patient came in my office for the first time. His vision is greatly improved. Of the right eye it is 20-40ths, of the left eye 20-30ths, but the perimeter reveals a limited field of vision, especially in the vertical direction of the peripheral field. The accompanying cut shows the exact field of vision taken March 24, 1890. The field of the left eye was slightly wider at the temporal and upper portions.
BY B. F. WILSON, M. D., SLATER, MO.
An operation, neither Syme's nor Pirogoff's, was recently thus performed :
James S. E-, age sixteen years, was injured January 12, 1890, at 5 P. M. The operation was performed the same day at 8 P. M., under antiseptic precautions. Method: Disarticulation at tibio-tarsal articulation by a dorsal incision from the internal to the external malleolus; exarticulation of the head of the astragulus, severing of inter-osseous liga
*Reported at the National Association of Railway Surgeons.
ment and removal of entire foot save the os calcis; os calcis left in situ, a segment consisting of its outer two-fifths being sawn off transversely ; malleoli sawn off, leaving articular cartilage; and sawn articular surfaces brought in apposition without cutting tendo-Achilles; large plantar flap brought up to close incision. Result: Temperature never rose above 101° F.; union by first intention was received, the first dressing being removed on the tenth day on account of pain caused by the silk thread left in the wound to insure drainage if needed. There was no pus.
In three weeks the patient was about on crutches, and in three months walking nicely with a cane.--Shortening one and one-half inch.
The advantages claimed for this are: The tendo Achilles is left intact, with no wounding of the adjacent tissues. There is no pocket formed where pus or septic materials may accumulate. The cicatrix is so situated (anteriorly) that it never interferes with the usefulness of the stump, being far better than those shown in figures 212, 214 and 216 in Wyeth's Surgery. Above all, the stump is a most serviceable one-the surface upon which the weight of the body is thrown being that accustomed to such service. viz.: 'the tissues covering the heel.
INACCURACIES IN THE USE OF DRUGS.
BY H. S. DOUGLAS, A. B., M. D., KANSAS CITY, MO.
Though selection of remedies, prescription-writing and dosage are by no means our most important functions in the care of a case; though they are often somewhat mechanical, yet drugs are universally recognized as among our best aids in controlling disease. Such being the importance of our armamentarium, it is the aim of this paper to consider, not therapeutics, but how carefully we use the various materials and preparations which the Pharmacopoeia places at our disposal ; in short, how accurate and exact is our prescription-writing and dosing. The practice of medicine is influenced by too many complex factors to be an exact science, but in the administering of certain well-known drugs there can surely be a near approach to precision. Let us see how near we come to it.
The great majority of our most useful medicaments have been known and used for many years, have been studied clinically and experimentally by a host of observers, and the resuts have been scientifically set forth in many works on materia medica. The skill of the pharmacist has done much in the invention of stable and concentrated preparations, and the fruit of their labors has been preserved in the Pharmacopcia. A combination of both is found in the ponderous volume of the Dispensatory.
Use of Drugs.—Douglas.
Of the various preparations of the Pharmacopoeia, among the most widely used are the tinctures and the fluid extracts; and they may be considered as a fair criterion of the agreement of therapeutical writers regarding the amount of the dose of any drug. Of these authors the most popular and widely studied in this country are Bartholow, with his abounding faith in drugs; H. C. Wood, the apostle of physiological action ; Stille, Ringer and Biddle. The works of all of these have been consulted in determining their uniformity in the maximum dose of important drugs. In this inquiry the work of Ringer may be excluded, as he deals but incidentally with the doses of the various preparations. In the exceedingly scientific treatise of H. C. Wood the dose is almost invariably given in drops, or other inaccurate or approximate measure. Biddle often neglects to speak of the greater number of preparations, giving the dose of but one or two. Bartholow alone methodically states the dose of all officinal and many non-officinal preparations, and hence is the most valuable for consultation in this matter. The Pharmacopæia directs that all Auid extracts shall be so made that each cc. of the extract shall represent one gramme of the drug, thus forming a fixed and definite preparation. The tinctures, however, are made to vary in relative strength in a manner purely arbitrary, for the tincture of some mild drugs is made weak, and requires a large dose, while the tincture of other powerful drugs, which act violently in small doses, is made as concentrated as possible, thus cutting down in some the amount safely given to the fraction of a drop. Surely, this is absurd.
. Taking up more in detail some of the prominent drugs of the materia medica, let us see how well the works of reference agree with themselves and with each other in the amount of the maximum dose of several important preparations :
Of the tincture of veratrum viride, the maximum dose is stated by Wood and Stillè as six drops ; Bartholow gives five minims, being nearly double the dose stated by the other two authors mentioned. But of the fluid extract Bartholow gives the dose as also five minims, the same as the tincture; but as double the amount of the crude drug is used in the preparation of the former as in the latter, it follows that Bartholow's dose of the extract is twice as powerful as that which he gives of the tincture; while it is four times more powerful than the dose of the tincture given by Wood and Stillè. Of cannabis Indica Bartholow gives one fiuidrachm of the tincture, and half a fluidrachm of the fluid extract; thus his dose of the fluid extract is two and one-half times as great as his dose of the tincture; a vast difference, and in case that an active preparation is prescribed, capable of producing serious results. Of digitalis Bartholow gives one fluidrachm of the tincture and but three minims of the fluid extract. In other words, his dose of the tincture is three times as great as that of the fiuid extract. Wood gives but twenty drops of the tincture, or one-sixth of the amount given by Bartholow; while Stille and Biddle give but one-third of Bartholow's dose of the tincture. Of the preparations of lobelia Bartholow gives two and one-half times as much in active strength in his dose of the fluid extract as he does of the tincture. The same holds true of aconite, as he orders a five-minim dose of each, while the fluid extract represents two and one-half times the amount of the crude drug represented by the tincture. This careless and unreliable manner of statement of the relative doses of each drug is found all through Bartholow's work, and adds little to its reputation as a reliable text-book and work of reference. Examples could be multiplied of the variations of the statements of different authors
egarding the dose of the same preparation, but the few instances quoted above will suffice to show how little dependence is to be placed upon our standard works on materia medica, in this important particular. Either our faith in the action of drugs is not founded in fact, or else great harm must often result from this hap-hazard way of prescribing aconite, digitalis, veratrum viride, or other powerful remedies.
But, aside from the books, we have to contend with yet other sources of error.
In ordering medicine in liquid form, a strict measure of each dose cannot be expected when administered by an inexperienced nurse. We are compelled, perforce, to depend upon those exceedingly elastic measures, the drop, the teaspoon, and the tablespoon. Often dessertspoonful doses are ordered for people who do not have a dessert three times a year, and who have no special utensil for such a movable feast. The drop is of more importanee. It varies widely, according to the nature of the liquid, the size. of the lip of the bottle, the angle at which the bottle is held, the temperature, and the rapidity with which the drops fall. In prescribing, this can be discounted to a certain degree, by bearing in mind, when ordering the dose, the density of the liquid and the necessary size of the bottle; but it becomes of far more importance when, as is too often the case, the physician himself confounds the drop with the minim in ordering the amount of any given preparation used in compounding his prescription. In prescribing full-doses of dangerous drugs, this is a consideration of importance. Five drops of tincture of aconite root dropped from a sixteen-ounce bottle is a very different matter from five drops from the minute tip of the medicine dropper, while each of these would vary materially from the five-minim measure; in certain cases these differences could produce fatal results. Tinctures of aconite, digitalis, etc., give 120 average drops to the fluidrachm, while only 57 are required to make the same measure of Fowler's solution ; and so forth, through all the liquid preparations of the Pharmacopæia, each will have a difference in the number of drops in any given measure. He who writes all his prescriptions on the assumption that 60 drops of any liquid will make one fluidrachm is guilty of a carelessness that might easily result fatally. It might be an open question whether many a pa