THE
American Practitioner and News.
“NEC TENUI PENNÂ.”
Vol. XXV.       Louisville, Ky., February 1, 1898.       No. 3

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 any thing else.—Ruskin.

SOMETHING ON THE DISUSE OF PHLEBOTOMY.

When I began looking into medical books preparatory to practice, fifty years ago, the standard authors given us to read were not backward in recommending blood-letting in the acute diseases; and a little later, when an attendant at lectures at the College of Physicians and Surgeons at New York, the professors were not lacking with the like advice. But there has come a change, and so much of a change that, in this section of country at least, the lancet has mostly gone out of use. That the frequent use to which it was put seventy-five or a hundred years ago was not at all times wise is likely; but the extent to which it has been given up is also not wise. Rather more to notice some of the reasons why it has so largely been abandoned than to argue for a reintroduction of that ready and efficient instrument is the purpose of this paper.

A prominent point in the consideration of this comparative abandonment of the lancet is presented in the question: Has there been such a change in the type of the acute inflammatory diseases from three or four generations ago as to render the abstraction of blood less necessary and less useful? There are plenty of sound, hard-headed old doctors who will give a negative reply to this query; and occasionally we may notice some of them putting themselves in print to that effect. A Baltimore practitioner not so very long ago said: “The necessity for the use of the lancet is as great at the present time as it ever was in the 86past; the type of the disease has undergone no such changes as to render the abstraction of blood unnecessary or improper in the successful management of all cases attended with a full, tense, and quick pulse.” Others speak the like; but the majority of opinion is not pronounced in that direction, but rather adverse. Conversations during a forty-four years’ practice with men who began their professional calling sixty years ago, when the lancet was in often call, is to the import that there has been such a change in diseases as renders the frequent resort to blood-letting less important than formerly; that there is less of the sthenic type in even inflammatory fevers, a more general disposition to take on what we call typhoid forms, and thus depletion, either by the evacuation of blood or the exhibition of reducing drugs, is not so beneficial in even the acute inflammatory diseases as formerly. This is the view that has been entertained by a large part of those who began practice half a century or more ago, and this view has been sustained by a large amount of written authority; but it does not go to the extent of justifying that degree of abandonment of bleeding that has prevailed for the last forty years. The general opinion of to-day is, that while positions like that taken in the quotation given are too positive, on the other hand our practice is quite too lax; for while we still believe in blood-letting to some extent, we but seldom make use of it. Now as to the why.

Perhaps the first reason why the lancet is less used than formerly is found in the fact, or rather in the belief, of the change indicated. It is largely accepted as true by the older men in the profession that patients do not bear blood-letting as well as three generations ago. Accepting this as correct, it rationally follows that we should bleed less. But this is only one of the factors in the account, and not the largest one. The opinion that the physicians of the early part of this century used the lancet too often is beyond doubt correct. The doctrine of the purely symptomatic nature of fever put prominently forward by Brousais, and earnestly championed by active and pushing minds a century ago, and which was generally received in Europe and in this country, gave such an unfortunate impetus to the use of the lancet as finally led to its abuse. Patients were bled for almost every thing; not only for the fevers of acknowledged inflammatory type, such as acute pleurisy and the like, were bled for, but also cases of typhus, typhoid, etc., upon the ground that the fever in the case was only a symptom of the inflammatory action and was to be subdued or lessened by antiphlogistic 87remedies, chief of which was the abstraction of blood. The theory of the essentiality of fever became lost sight of, and the doctor treated for an inflammation rather than for a fever.

Without giving up the theory in which they had been educated, some physicians began to see that in some epidemics of disease a larger percentage of cases were lost among those where venesection had been used than among those similarly sick who were not bled. The deduction from this was that it would be better to bleed less. But a change was not to be made without a struggle. Reference to the medical literature of the first half of the century shows that there was a deal of warm discussion between the blood-letters and the anti-blood-letters. Out of the observations and discussions made there was cultivated a prejudice, professional to a moderate extent but popular to a large one, against bleeding per se, and without reference to the character of the disease under treatment or to the differing conditions that might exist, which helped to carry the usage from its former abuse at times to the opposite extreme of general abandonment. It is a universal law in nature that the farther the pendulum swings in one direction, the farther will it swing in the opposite on its return. The pendulum of venesection had swung too far forward for the best in the treatment of disease, and the return carried it quite beyond the best in the backward reaction.

Beyond the reasons noted for the present comparative non-use of the lancet, there has been added a pressure of an erroneous and illegitimate nature that has aided to put bleeding under a general ban more unfortunate for the sick than was the former rather indiscriminate use. Somewhat contemporaneously with the warm discussion upon bleeding carried on in the profession, and perhaps partly out of that discussion, there started up in various parts of the country an illegitimate class of practitioners, mostly illiterate and destitute of preliminary culture, interchangeably known as Botanics, Thompsonians, Eclectics, etc., whose chief stock in trade for public acceptance was denunciation, without regard to the conditions that might be met in a case, of leeching, bleeding, blistering, scarification, and other agents for cures. This denunciation found ready public credit. Not only from the mouths of the class named, but in various other ways, the prejudice they sought to create was widely diffused. Outside of the libraries of the profession you seldom see a medical book; anywhere else they have been rarities. But in many sections of the country for the last 88sixty years a canvass of the families would show an abundance of books, published for family reading, emanating from irregular practitioners, all of them saturated with lying abuse of the methods of treatment of the regular physicians. These books were loaned from one family to another, much as the weekly papers or the cheap novel; and they were read and believed in. The result was that many who read were indoctrinated with the belief that bleeding, no matter what the disease or the conditions, was not only not necessary, but pernicious, and often the cause of death; and there was little printed contradiction offered to disabuse the public mind of this false accusation.

Co-ordinating with this means of false instruction has been and is the public press. As respectable practitioners do not stoop to the quackery of advertising, the pecuniary interest of the press, so far as means and methods for the cure of diseases is concerned, is identical with the pecuniary interests of advertising quacks. The public press sells itself to the broad diffusion of the ways and means of medical quackery in all its forms. The subsidies of impostors and patent medicine men fill up one carotid artery for the support of the press; and the influence of that press, however weak the intellect that bestrides its tripod, is more potent than a hundred of the ablest men in the profession, for the sufficient reason that the voice of the men in the profession seldom strikes the public ear through the same broad and forceful channel.

The result of the false teaching of the class of books alluded to and of the medical advertising, and of the bleating of the tramping lecturers was that a large part of many communities came to believe that blood-letting was a crime against health, and a hindrance to recovery from disease, no matter what might be the conditions. The average intelligence of even well-educated communities goes no further than to accept the plausible teaching that is every day thrust upon its tympanum; it does not stop to criticise the motives nor to analyze the arguments of the advertiser, nor is it cultured in this direction to the capacity of justly weighing them according to their true significance. The average intelligence of even well-educated communities is not up to that grasp of the science of medicine necessary to determine between false and fallacious teaching and that which is rational and correct; it does not differentiate between clap-trap and honesty; it does not separate humbug from truth, and as an ocean of humbug passes the public gullet easier than an ounce of truth, it is not strange that 89the condition obtaining about bleeding is not so much that the physician has discarded it as improper, or has lost sight of its value in many cases, as that the community will not tolerate him in the abstraction of blood. Public prejudice overrides professional opinion, unless the opinion runs current with the prejudice. To bleed your patient and then have him die is to be damned; if he dies without being bled, no matter whatever else you may do or leave undone, the chances of being cursed are largely lessened. Besides this, very little or nothing is gained against the prejudice by recovery after bleeding, since the popular opinion will be that the patient would have gotten well quicker and better without it—an opinion that can seldom be disproved. Exactly in the same way in any case where venesection has been practiced and the patient does not get well, the opponents of the operation will assert that the bleeding caused the death, and that, in the absence of it, the patient would have got well; which also is difficult to disprove. The average mind proceeds from supposed causes to effects with most unreasonable logic.

As a matter of fact, the whole art of the practice of medicine is involved many times in many uncertainties as to the effects that are to follow the administration of drugs or the institution of any procedure, however simple, that it may puzzle the most sagacious to determine the exact weight of any factor introduced, whether it be for good or for ill. It should not therefore surprise us that to minds quite unacquainted with the therapeutical effects of blood-letting in disease, a death that follows a bleeding, however remote in point of time, should be credited to the operation rather than to the disease for which the operation was performed. An uncertain percentage of cases of many acute inflammations will recover, whether bled or not; an uncertain percentage of them will die, whether bled or not, and no matter how treated; and, while it will sometimes happen that of two cases of the same disease the one that is bled will get well and the one that is not bled will succumb, it will the next week happen that of two other cases of the same trouble the one that is bled will slip off and the one not bled will hold on finely. And it is a notorious fact that in some communities, if a patient is bled and then dies, nine out of every ten persons in the neighborhood will say, and part of them will believe, that the bleeding was an accessory if not the chief cause of the untoward event; and it is usually quite impossible for the doctor to show that the nine are not right in their view of the matter.

90Under these circumstances it can hardly surprise us that the use of the lancet has gone out of fashion. It is not so much that we have less faith in its beneficence, rationally employed, as that our patients are opposed to it. Whether in spite of the opposition we should employ it oftener than we do is a question that every one must settle for himself. It might be possible for a bold and determined man to work up that road to confidence with his patients in it, but the path is so beset with difficulties that a hundred will fall by the way where one succeeds. A single death after phlebotomy will do more to impede the success of a young man in the profession than a dozen deaths without it; it is wise therefore to be cautious in the use of so potent a remedy, and to sin less in commission than in omission of opening a vein. It may be said that whether he succeeds or fails it is the duty of the physician to do in all cases what he thinks will be the best for his patient. This position may have its merits but it is a better thing to teach than to act upon. There is no law of right that demands of the practitioner that he shall assume the responsibility of the stupidity and ignorance of all his patients, and, worse still, of all the irrational prejudice they have allowed themselves to imbibe, and which no amount of logical facts will dispossess them of.

The writer, in the nearly fifty years of his practice as student and graduate, has had an average share, perhaps, of his patients die; but he has never had one die of any sort of fever after he had been bled as an aid in subduing that fever. On the other side, he has had patients die of the acute inflammatory diseases when they have not been bled; and, to-night, recalling those cases, he is of the opinion that some of them, if they had been well tapped in the arm at the outset of the sickness, they would have been saved.

Pepsina porci, the pepsin of the hog, was one among the first of the animal products to be used in medicine, and many physicians, not well versed in organic chemistry, supposed that in it they possessed a sovereign remedy for indigestion in all its forms and stages, and the confirmed dyspeptic had only to apply the specific to have his digestive apparatus restored to its youthful health and vigor. Unfortunately for this view and for the sufferers, the fact was overlooked, or not duly appreciated, that pepsin is only one of several substances which Nature employs in the complete digestion of food, and that the products or secretions of several different glands have a part in the process, each of which is essential to the proper preparation of food for the nourishment of the human body.

It has been estimated by competent observers that as great a proportion as seventy-five per cent of all the intractable cases of dyspepsia in this country are caused primarily by faulty saccharification of the starchy foods which constitute such a large portion of the diet of the American people. This being the fact, is it any wonder that the administration of pepsin alone should fail to give relief in many cases? It fails because the fault lies, not in the stomach, but in the salivary and other glands whose secretions possess the amylolytic property, and the remedy is the administration of substances that will restore that property to the secretions, or which possess it in and of themselves.

Until quite recently the practitioner was compelled to rely for this purpose upon the various malt extracts upon the market, the diastatic power of which was so feeble that the service they rendered was but slight. What was needed, and for which many of the most patient investigators were searching, was a diastase which would do for the starchy elements of the food what pepsin does for the proteids. The digestion of food in man has been the subject of much patient and methodical study and investigation during the last two decades, notably by Ewald, Kellogg, Hayem, and Winter, and others, resulting in the placing of the therapeutics of disordered digestion upon an exact scientific basis. It is not, however, necessary for the purposes of this 92paper to go very deeply into the minutæ; a superficial survey will suffice.

Digestion begins in the mouth with the act of mastication, the presence of food in the mouth, or even the thought of it, acting upon the salivary glands to produce a free flow of saliva, which, being thoroughly incorporated with the food by the act of mastication, exerts its peculiar influence upon the starchy constituents, converting them into dextrose, maltose, etc. This amylolytic action lasts but a short while, the ptyalin of the saliva being active only in neutral or slightly alkaline media; consequently when the food reaches the stomach and peptic digestion begins, its effect ceases.

The saccharification of the starchy elements of the food before reaching the stomach serves to separate or disentangle them, as it were, from the proteids, and deliver the latter to the stomach in the condition most favorable to the action of the gastric ferment or pepsin.

The stomach, after a variable length of time, during which the peptic ferments accomplish their allotted task more or less thoroughly and completely, delivers the resultant mass over to the small intestine, where the secretions from the pancreas, liver, and intestinal glands, by finishing the transformation of the starch begun before the stomach was reached, emulsifying the fatty constituents, etc., complete the complex work of digestion.

It will be seen from the foregoing that the derangements of digestion may, for ordinary clinical purposes, be divided into three classes, each of which is distinct from either or both of the others, although they shade into each other by imperceptible gradations, so that there are no well-defined boundary lines separating them. The first class includes all those cases which are characterized by a deficiency, in quality or quantity, of the salivary secretion, and a consequent failure of or interference with the digestion of the starchy elements of the food—amylaceous dyspepsia. The second includes those in which there is difficulty in the digestion of the proteids, due to a variety of causes—gastric dyspepsia. In the third is placed those cases in which the trouble is located below the stomach, and are caused by inability of the pancreas and other glands to normally perform their function—intestinal indigestion.

One constantly meets with cases belonging to each of these varieties, and he must correctly diagnose each case if he would apply the treatment necessary to produce the best results. For the present, however, 93we have only to do with the first variety, as my object in the preparation of this paper is to direct the attention of the profession to a new diastatic ferment which acts with as much or even greater energy upon the amylaceous foodstuffs as does pepsin upon the proteids.

Such a substance has long been a desideratum with those who treat many dyspeptics, and who have been compelled to content themselves with malt extracts with which the market is supplied. The substance referred to was discovered by a Japanese chemist, Jokichi Takamine, not as the result of accident but while working scientifically with that exact end in view, and is now supplied to the profession by Parke, Davis & Co. under the name of Taka-Diastase. The writer has had frequent occasion to use it since it was first brought to his notice about a year and a half ago, and in that time has not had a single case in which its administration was not attended by the very best results. Notes of several cases were kept, three of which will be presented here as the most appropriate conclusion.

Case 1. L. A., white male, age thirty-eight, a barber by occupation, consulted me first in the fall of 1894. He was at that time, as he had been for several years, the victim of a most obstinate and intractable form of dyspepsia. He had been a coal miner until forced by ill health to quit that for some lighter occupation. He, however, continued to grow worse until, when coming under my care, he was very much emaciated, weak, nervous, and irritable, his stomach unable to retain any thing save the blandest articles of diet, and those only in small quantities. Treatment was begun by regulating his habits, diet, etc., and putting him on an emulsion of bismuth subnit. and pepsin pur. immediately after eating, and tr. nux vom., hydrochloric acid, and tr. colomba before eating. His condition improved somewhat under this treatment, but only to a limited extent, and it became evident that more efficient measures must be resorted to if we hoped to accomplish permanent good. It had been noted that a meal, however scant, composed mainly of starchy substances was always productive of an acute attack, and acting upon this suggestion extract of malt was added to the remedies he was using, and, to a certain degree, with good effect. He, however, did not go on to complete recovery, but the improvement ceased at a certain point, and in spite of continued treatment with the remedies mentioned his condition remained about stationary. Unable to work, morose, cross, and irritable, existence was a burden to himself 94as well as family and friends. At this juncture my attention was attracted to Taka-Diastase and a supply was at once procured. The patient was given a number of capsules containing five grains each, with instructions to take one capsule at the beginning of each meal, continuing the bismuth and pepsin mixture as before, immediately after eating. In a very short time improvement was discernable, and from that time was rapid and continuous. The treatment was kept up, with the addition later on of ferruginous and bitter tonics, until there could be no doubt of his complete and permanent restoration to health. He has now been at regular work in the shop for several months, and says that he “never felt better in his life.”

Case 2. Mrs. J. H., a white woman, aged forty-six, wife of a well-to-do farmer. Until within the last year or two had enjoyed the best of health, and was inclined to stoutness in consequence. Dyspeptic symptoms had troubled her more or less during the time mentioned, and of late had increased in severity so much that she asserted, at the time she consulted me, that if she dared to eat any thing at all she suffered the greatest agony in consequence. A neighboring physician had treated her for some weeks previous to her visit to my office, and, as I afterward learned, had given her the regulation treatment with pepsin, bismuth, hydrochloric acid, etc., with results so discouraging that she had lost all hope of receiving any benefit from “doctor’s medicine,” as she called it, and it was only at the urgent solicitation of husband and friends that she came to me for treatment, being careful to inform me that she had no idea I could help her in the least.

Her case was diagnosed “amylaceous dyspepsia,” and she was given Taka-Diastase in eight-grain doses, half of which was to be taken before eating and the remainder during or after, with tr. nux vom. and hydrochloric acid, in moderate doses, ter in die.

Despite her determination not to be benefited by “doctor’s medicine,” the improvement was prompt and continuous, and so manifestly due to the treatment that she soon forgot or overcame her antipathy, and with characteristic inconsistency now asserts that it is impossible to get along without it. She eats three meals regularly every day, and suffers no inconvenience whatever in consequence.

Case 3. W., a white male, aged forty, had never had any serious illness, and digestion had been especially good until about four weeks before consulting me. At that time he, in company with some friends, ate quite heartily of watermelon. He had always eaten watermelon 95freely and with impunity prior to that occasion. It did not agree with him so well that time, and in a few hours he was seized with an acute gastralgia of the most severe character, and from that time to the present he has had more or less trouble of that kind, even a very small quantity of food, especially if it be of a starchy nature, giving rise to the most distressing symptoms.

The diagnosis of amylaceous dyspepsia was also made in this case, and he was at once put upon the Taka-Diastase in doses of five grains given with the meals, and temporarily excluding starchy foods from his diet as much as possible without too great inconvenience. There was also great torpidity of the liver, and for that he was given sod. phosphate in teaspoonful doses every morning before breakfast, taken in a gobletful of hot water. Under this treatment improvement was satisfactory and rapid, and with the addition of bitter tonics later on he was ultimately restored to complete health.

Remarks. Case 1 was an example of that class with which, prior to the introduction of Taka-Diastase, the general practitioner was too often compelled to acknowledge his inability to cope successfully. In them there is difficulty in the digestion of both amylaceous and proteid substances, and the remedies usually recommended were efficacious only so far as digestion of the latter was concerned, and did not reach the former at all. The cure was incomplete, and must have remained so until the substance we have been considering, or something analogous to it, was furnished the physician with which to complete it.

Cases 2 and 3 were examples of the first class mentioned above, viz., amylaceous dyspepsia, and while under treatment with pepsin, etc., they were considered the most intractable of all; under Taka-Diastase they yield rapidly, and are cured in a surprisingly short time.

LOUISVILLE MEDICO-CHIRURGICAL SOCIETY.^[1]

Uterine Fibroma. Dr. L. S. McMurtry: I present this specimen of uterine fibroma on account of two very interesting features of this class of tumors which it illustrates. The first relates to the morphology of these growths. The tumor is a very large one, and occupied the entire pelvis and the abdomen to the superior limits of the umbilical and lumbar regions. It is a multi-nodular tumor, and its disposition in relation to the fundus of the uterus is unlike any specimen that I have ever encountered. It will be observed that the neoplasm springs from the lower segments of the uterus, and the fundus is not involved in the growth at all.

The second feature of interest, and this is especially interesting from a surgical point of view, is the relation of the bladder to the tumor. It is very common for the bladder to be carried upward with the growth, thus rendering it very liable to injury in operation. This feature is exceptionally conspicuous in this tumor on account of the nodular condition where the bladder was attached, forming a sulcus. In releasing the bladder, after splitting the capsule, the uneven surface of the tumor caused me to inflict an injury upon the coats of that viscus. After dissecting off the bladder I found that I had made an opening in it at this point. It was immediately closed with a double row of catgut sutures. The operation was done six days ago, and the convalescence of the patient has been most satisfactory indeed. The bladder injury has not complicated the patient’s convalescence at all, its function being carried on just the same as if it had not been involved. The convalescence has been afebrile from the beginning, and recovery is assured.

The method I observed in treating the pedicle was to amputate the cervix very low down, leaving a very small rim of the cervix, and suturing the peritoneum over it all the way across the pelvis, making the pedicle extraperitoneal. The conformation of the growth and its 97relation to the cervix uteri made this method of dealing with the pedicle especially applicable in this particular instance. The patient is thirty-four years of age, and the operation was urgent on account of persistent hemorrhage and marked pressure symptoms.

Discussion. Dr. J. A. Larrabee: I would like to ask the reporter for what length of time this tumor had been developing?

Dr. L. S. McMurtry: The woman was thirty-four years of age, and according to the history obtained the tumor was first noticed three years ago. The patient has made a beautiful convalescence. I present the specimen on account of its morphology, and because of the difficulties that might be encountered in performing an operation in such cases by the bladder being impacted in the sulcus.

Tubercular Testis. Dr. W. O. Roberts: This patient is twenty-four years of age; his father and mother are living; father sixty-four, mother fifty-four; his grandfather on his father’s side died at the age of sixty-four of what was supposed to be consumption; his father’s twin brother died at the age of twenty, after an illness of eight months, of consumption; his mother’s family history is good.

This young man had gonorrhea seven years ago, with orchitis of both sides as a complication, the left testicle swelling first, then the right; the swelling lasted in each for about two weeks. Had gonorrhea again in November, 1896, and says again in December of the same year. At this time he noticed that his left testicle was getting hard in places and was swollen, but there was never any pain. The inflammatory process has never been very acute. However, he noticed after taking a horseback or bicycle ride the testicle would be somewhat tender. Had another attack of gonorrhea during the month of September of the present year, which he says lasted only two weeks, and during this attack the testicle was also affected.

He now has a swelling of the left testicle, and a hardness about it and in the epididymis, which I would like for the members to examine, expressing an opinion as to the nature of the trouble.

Discussion. Dr. J. M. Ray: I do not know that the ocular symptoms will throw any light upon the case. I remember that this young man came to me some time ago to have his eyes examined. He stated that he had been under the care of a prominent oculist in the South, and had been fitted with glasses. When I saw him he had some 98trouble in the use of his glasses, and also complained of defective sight of one eye. Upon examination I found a spot of atrophy of the choroid, showing the location of a former acute choroidal disease, and there was considerable diminution in acuteness of vision in that eye, with a defect in refraction in the other eye. Under mydriatics I fitted him with glasses, since which time he has been perfectly comfortable so far as his eyes are concerned.

He states that he remembers I said something to him at that time about tubercular disease, after looking into his eyes, but I have forgotten the circumstance; I only remember that I found choroidal disease.

Dr. J. A. Larrabee: Of course we are all led somewhat by the diathetic history of our cases. Chronic inflammations tend to take on the part of the diathesis. I did not understand the reporter to say that any test had been made, by withdrawal of some of the fluid or otherwise, to determine the exact nature of the condition. I desire to say, however, that if this were my testicle I would have it removed. I believe that would be the safest plan. An absolutely positive diagnosis would be difficult to make without a microscopical examination for the tubercle bacillus, but I can not help feeling prejudiced in that direction.

Dr. J. L. Howard: I agree with Dr. Larrabee as to what should be done with this testicle; it should come out. I, too, think it tubercular, although in all probability the gonorrhea is a factor in the case in stimulating the growth of the testicle. I do not know that a microscopical examination would give us much light upon the subject; in fact I would not wait for that, I would simply remove the testicle at once.

Dr. Wm. Bailey: The question is not by any means settled as to the exact nature of the disease in the case before us, whether the patient, having had repeated attacks of gonorrhea, has not also been so unfortunate as to have syphilis. With a tuberculous history of course a tuberculous condition of the testicle seems plausible; but inasmuch as tuberculous disease of the testicle may remain for a long time possibly without great danger in affecting the patient otherwise, and knowing the changes that take place in the testicle from repeated attacks of gonorrhea, orchitis, etc., I believe if it were mine I would be disposed to keep it for a while, particularly as the other testicle seems to be somewhat atrophied, with this one of pretty good size. I think I would keep the larger one.

99Dr. T. S. Bullock: I am inclined very much to agree in the opinion expressed by Dr. Bailey. I have frequently seen, after repeated attacks of gonorrhea, a testicle that had become enlarged, without any pain. The testicle in this case appears to be perfectly smooth, and in view of the fact that tubercular disease of this organ may exist for a long time without affecting the general system, I should certainly keep the testicle until my general health began to show some evidence of declination.

Dr. F. C. Wilson: The question is a very difficult one to decide. There is one feature of the case that has not been sufficiently emphasized, and that is the probable damage to the testicle itself by the repeated attacks of gonorrhea. We know that the use of the testicle, so far as any procreative uses may be concerned, has probably been abrogated by these repeated attacks of gonorrhea, and with this view of the case the question of removal of the testicle by surgical means would be simplified; and it seems to me with the tuberculous history, if the question could be decided even approximately, or even probably, that it is tubercular, then it had better be removed. But it seems to me I would first make every effort to solve the question, even aspirating or removing a small part of the tissue so as to be able to make a microscopical examination, and in that way possibly throw some light on the subject.

Dr. W. O. Roberts: It strikes me that this is tubercular, although it may have been, as Dr. Howard says, excited by gonorrhea. The condition feels to me nodulated and not smooth, and the disease appears to be located chiefly if not entirely in the epididymis, and I think the testicle should be removed. Whether it is tuberculous or not the usefulness of the organ is destroyed, and I think it ought to come out if it is tuberculous, especially because the other testicle will become involved. So far as the cosmetic appearance is concerned, if that is a feature in the case, we could insert a celluloid testicle. I believe if the affected testicle is not removed, granting the diagnosis of tuberculosis to be correct, that the other testicle will surely become involved.

Dr. Turner Anderson: It is seldom that we have obstetric matters presented to this society. I have thought perhaps a case I recently attended might be of some interest. We are aware that the umbilical cord is frequently found encircling the neck of the child. I delivered 100a child four days ago in which the cord was wrapped around the neck twice, then branched off under the arm, encircling the arm again at its dorsal surface, then across again, branching over the back. You may better understand the condition when I say that the cord came up from its attachment at the umbilicus, encircling the neck twice, branching over and under the axilla, around the arm, thence to its attachment to the placenta. The woman was a primipara. As soon as the head was delivered I detected that the cord was wrapped around the neck. I made an effort to find the part that led to the placenta. The cord was found pulseless, and I was in some doubt as to whether it had been so long encircling the neck as to have produced death of the child. Just as the body of the child was being extruded the cord snapped, tearing off fortunately from its placental attachment. The child was delivered and after a little effort was easily resuscitated. The pressure was so great, the traction upon the cord was so decided, as to leave a white line across the back of the child. There was a white mark around the neck, across the clavicle, around the arm and over the back of the child which did not disappear for some time afterward.

The proper line of practice, I take it, in those cases where the cord is around the neck of the child, is to first determine whether the cord is still pulsating. If pulsating, we are justified in being a little more tardy in our efforts to deliver the shoulders and release the child. If possible we would of course draw down the cord and release it from the neck of the child in this way; but in those cases where we are confronted with the cord wrapped tightly around the neck of the child, especially in the primipara, where the length of time which will be consumed in delivery is uncertain, the line of practice I believe in should be prompt delivery or division of the cord. As a rule when we are confronted with a condition of this kind we can meet it satisfactorily by a little delay and by holding the head of the child well up against the vulva while the shoulders are being extruded. As the releasing pain occurs and the shoulders and body are extruded, you can usually by pressing the head well up prevent undue traction on the placenta and any accident which might follow rapid delivery and undue traction upon the cord. This was a case in which there was spontaneous rupture of the cord; it tore away entirely by the uterine effort. This accident had no influence upon delivery of the placenta; it came away promptly. It was evidently not torn loose from its attachment, and there was no hemorrhage.

101Discussion. Dr. J. A. Larrabee: The case is not only interesting, but also somewhat unique as far as I am aware. We are all familiar with the double wrapped cord, but in this case the acrobatic movements of the child must have been considerable, in utero, to have produced the condition described by Dr. Anderson; the child had evidently been engaged in jumping the rope for some time. When the cord is wrapped around the neck of the child as described, I think the best plan is to expedite delivery. Of course in the primipara we must not be in too great a hurry, we must utilize melting or crowning pressure to prevent injury, but the management of these cases I think is entirely that of dystocia, and powerful external pressure upon the fundus of the uterus, bringing it down as low as possible, is the proper plan of expedition. In the case reported, however, no amount of external pressure would have accomplished any thing; fortunately the snapping of the cord enabled the doctor to deliver and resuscitate the child, which is about the only thing that could have been done. In this case it would have been almost impossible to have divided the cord. Aside from the anomaly of the case, which is worthy of especial mention, I do not know of any proceeding which would have been equal to that which was followed. It is a little strange that the placental attachment did not give way; if this had been true, if there had been a separation of the uterine attachment of the placenta, then we would have expected the placenta to have been expelled with the child instead of a rupture of the umbilical cord.

Dr. J. L. Howard: I would like to ask Dr. Anderson if usually, when the cord is wrapped around the neck of the child, the cord is not an abnormally long one? I have had this accident happen twice in my experience, but no trouble resulted because of the abnormal length of the cord in each instance.

Dr. J. G. Cecil: This is an accident which as we know happens frequently, as well as many other anomalous things in connection with the umbilical cord. I would have been disposed, if the labor had been delayed in this case, that is, the final delivery of the child, more than four or five minutes, to have severed the cord, fearing that it might have had something to do with the delay. If there was no pulsation in the cord, there would have been little risk in cutting and not tying it; then there would have been no further delay to the delivery; there would have been no danger from hemorrhage, from premature separation of the placenta, or danger from inversion of the uterus. However, 102as the case turned out so well under the management that was adopted, it does not become us to criticise that management, because the successful issue proves the wisdom of the plan followed.

I have once or twice encountered some delay in expulsion of the child by reason of a short cord wound around the neck. I have never seen one so displayed around the shoulder as in the case reported by Dr. Anderson. I remember to have seen one case, however, in which there was a knot tied in the cord, and tied so tightly that it shut off the circulation and resulted in death of the child, and also complete atrophy of the cord between the knot and the navel end. This was a very interesting case, and was reported to the Louisville Clinical Society three or four years ago by Dr. Peter Guntermann; it was one of the most interesting cases of accidents to the cord that I have ever seen. How the knot was tied so tightly in the cord can not well be explained; knots in the umbilical cord are not very unusual, but it is unusual to see one tied so tightly that the circulation is shut off thereby. It was thought, I believe, by the reporter on that occasion that the accident was due to a fall which the mother sustained just before the delivery, which was premature.

Dr. Wm. Bailey: Nothing in the management of the case reported by Dr. Anderson can be criticised by me. I am inclined to think that under no circumstances was pressure made on the cord sufficient to interrupt the circulation until after the head of the child was delivered. Then it became a question as to the proper management. I believe it would have been better to have cut the cord, as it might have lessened the difficulty of delivery, and that there would have been no harm done to the child in this case, because there was no pulsation in the cord. The doctor had all the time for this delivery that would have been allowed him if he had a breech presentation with the head making pressure upon the cord, and ordinarily he would deliver such a case in from five to seven minutes, and that would give a chance for resuscitation of the child just as in the case of drowning. The child can be deprived of circulation through the cord, in an accident like this, as long a time as a person can be submitted to water, or drowned, and be resuscitated. I have seen but one case in which there was a rupture of the cord during delivery. I saw one exceedingly short cord, in which delivery of the child ruptured the cord; it was not around the neck, it was simply too short for the child to be delivered without detaching the placenta; just as the child was delivered the cord was 103spontaneously severed at the umbilicus, simply allowing me a sufficient amount to be caught with the fingers and held until a ligature could be applied. I do not remember the exact length of the cord, but it was so short that it was not possible to deliver the child without either breaking the cord or detaching the placenta. The cord ruptured spontaneously, and there was no further accident or trouble.

I believe if Dr. Anderson had to attend another case under exactly the same circumstances he would prefer to cut the cord rather than to break it off at the placental attachment. Inasmuch as he did not cut the cord and the child was successfully delivered, and also as there was no trouble in delivering the placenta, of course it makes no difference; but I always like to have the cord attached to the placenta so that if it becomes necessary to go after the placenta, in case of retention for instance, I can have the cord as a guide. In Dr. Anderson’s case there was no possible advantage in having the cord intact; as it was pulseless, no injury could have been done the child by cutting the cord before completing the delivery, and by cutting the cord as soon as it was found that it encircled the neck, all possible difficulties as far as the cord preventing delivery was concerned would have been removed.

Dr. T. S. Bullock: I am very much interested in this case; I have never seen one exactly like it. The greatest danger in this particular instance was that alluded to by Dr. Cecil, viz., producing inversion of the uterus. I think Dr. Anderson managed the case in the proper manner, and by his method of expression the only possible danger was inversion of the uterus.

I have only seen one instance of dystocia from short cord; that was a case in which the cord was the shortest I ever saw, and was wrapped around the neck, where it was necessary in order to deliver the child to cut the cord after tying it and then employ instruments, the cord being so short that with each uterine action you could feel the cupping of the uterus from tension on the cord.

I think there would be less danger from premature separation of the placenta than from inversion of the uterus. In the case Dr. Anderson has reported the danger to the child from compression of the cord was obviated by prompt delivery.

Dr. J. A. Larrabee: Will not Dr. Bullock tell us whether the case he refers to, where he could feel a descending or cupping of the uterus by the expulsive efforts, was a primipara?

104Dr. T. S. Bullock: The woman was a primipara; the cord was very short, it was tied and severed, then the delivery completed with forceps. I would like to ask the gentleman whether, in those cases where they have employed Crede’s method of delivering the placenta, they have noted a cupping of the uterus from efforts to extrude the afterbirth?

Dr. J. A. Larrabee: I have occasionally noticed cupping of the uterus under those circumstances.

Dr. F. C. Simpson: I remember a certain practitioner in this city several years ago made the statement that he seldom tied the cord after cutting it; that he did not see any necessity of tying the cord. If this is true, then there would certainly be no danger in severing the cord in cases such as Dr. Anderson has reported, and it would not even be necessary to tie it until after the delivery had been completed.

Dr. Wm. Bailey: I want Dr. Anderson to speak to one point in particular in closing the discussion, viz., would there not be great danger if the placenta was separated at a time when the child was still partly in the uterus?

Dr. F. C. Wilson: The only point I wish to bring out in connection with the case is the possibility of detecting the fact that the cord is around the neck of the child before delivery, and being on our guard for it. Encircling of the cord around the neck of the child ought to give rise to a funic bruit. You can hear very plainly a funic bruit, a bruit which is synchronous with the fetal heart sounds. Where this can be detected at a point where we know the neck of the child lies, it indicates to us that the chord is around the neck.

There are certain other circumstances under which we may also detect a bruit: For instance, the one mentioned by Dr. Cecil, where the cord was tied into a hard knot. I have met with several such cases in my practice, and a bruit can be produced in this way, but at a different place from the location of the neck, and it is a permanent bruit; a bruit that is heard all the time. Where that is the case, of course it indicates that there is some permanent obstruction of the cord, and the likelihood is that it is due to a knot tied in the cord. We know that sometimes the cord slips over the neck, and then the child’s body slips through the cord, thus making a perfect knot; it then may be drawn tighter and tighter, finally producing considerable obstruction. If the bruit that is heard is evanescent, heard sometimes when you are listening and not at others, that indicates simply a temporary 105pressure upon the cord which may produce a bruit that is fetal in its rhythm, at the same time it is heard occasionally only. Where the cord encircles the neck and is drawn tightly it is apt to give rise to a bruit that is more or less permanent, and always heard at a point where we know from other methods of examination that the neck of the child is located. Where this occurs we ought to be on the lookout and prepared to find the cord encircling the child’s neck, and ought to endeavor to release it in the first place, and where we are unable to do that, then the question of severing the cord will come up. The cord being pulseless in the case reported by Dr. Anderson would have simplified that question very materially. The cutting of a cord that is not pulsating is an easy thing and not at all dangerous. Even where the cord is pulsating I have cut it repeatedly without even attempting to tie it, simply holding one end—of course you have to make a guess as to which end is attached to the child. You can not always tell that, but you can easily see from the continued bleeding or pulsating whether you have the proper end or not, and by simply holding that between the fingers the delivery can be expedited, and then the cord can be tied immediately afterward. Where the cord is pulseless there would be no danger in severing it and leaving it untied and even unheld. I have time and again, after delivery of the child, cut the cord and not tied it, but always waiting till pulsation had ceased. I think there is no danger in doing this. If a cord is cut after it ceases to pulsate and does not bleed by the time the child is washed and ready to be dressed, there will be no hemorrhage from it afterward.

Dr. Turner Anderson: Referring to the point made by Dr. Howard, I believe, whenever the umbilical cord presents anomalies as illustrated by the case reported, that it is as a rule abnormally long. The cord in this case was abnormally long.

Dr. Larrabee made a point to which considerable importance should be attached, viz., that it would not have been an easy matter to have divided the cord in this case. I think practically he presents the case exactly right. When a cord encircles the child’s neck twice, then branches off and goes under the arm, then branches off over the back, it presses the neck so tightly and the conditions are such that it would be a very difficult matter to get one’s finger beneath the cord at the neck and divide it. It is not such an easy matter to sever a cord under these circumstances as one might suppose. I believe the majority of obstetricians content themselves, when they find the cord is 106encircling the neck, by simply making an effort to stimulate uterine contraction, and to deliver the child as rapidly as is consistent with safety to the mother, and while so doing take the precaution to support the head, to hold it up well against the vulva and prevent undue traction on the placenta.

It is seldom that we fail to resuscitate a child born under these circumstances. The cord as a rule is not encircling the child so tightly so as to prevent our ability to resuscitate it.

Dr. Bailey has correctly stated that arrest of pulsation in the cord does not occur until after delivery of the head, and we have a limited time then to stimulate uterine action and to disengage the body of the child and release the cord from the neck. Contraction and arrest of pulsation of the cord do not occur prior to that time as a rule. I can conceive it possible that it might do so, but as soon as the head is delivered, contraction then is so great that unless the cord is very long there is an arrest of pulsation and the danger commences. Fortunately we have recourse to stimulating uterine action, and have a chance to deliver the child in the manner I have suggested with sufficient promptness.

I am satisfied Drs. Bailey and Bullock recognize all the dangers of premature separation of the placenta in an uncontracting uterus. In the primipara I can not believe that a slight cupping of the uterus, or the premature separation of the afterbirth, would be a matter of any very great moment. We are all agreed as to the dangers which may occur from separation of the normally attached afterbirth prematurely in the absence of uterine action.

In the primipara we know how very closely the perineum, unless it is lacerated, hugs the neck of the child, and to isolate and cut the cord under such circumstances is a very difficult matter. I do not attach much importance to not cutting the cord, although if I could feel it around the neck of the child and could sever it I would not hesitate to do so.

Protrusion of the Rectum. Dr. W. O. Roberts: To-day at my clinic at the University of Louisville a man presented himself complaining of hemorrhoids. I put him on the table on his back, drew his legs up to make an examination, and he strained slightly, had an action from the bowel, and passed out about four inches of his rectum. After examining it carefully to see whether or not there were any hemorrhoidal 107masses about it, or a tumor of any kind, I started to get some vaseline to assist in replacing his rectum, when he drew it back himself as though he had a string fastened to it. He did not touch it, but simply drew it back. I turned the table about so the class could see the prolapsed rectum, and he shot the rectum out and drew it back four or five times. It is a very peculiar and unique condition to me, and I would like to inquire if the members have ever encountered a condition of the kind in their practice.

Discussion. Dr. J. M. Williams: This is undoubtedly a case of prolapse of the rectum with a lax condition of the connective tissue. It may be from continually coming down, and I have no doubt that the bowel comes down after each defecation; there is some kind of an action by which the patient controls the rectum. It may be that contraction of the sphincter muscle starts the rectum upward, and then it simply follows its course. I can offer no other explanation of the condition. Certainly if the bowel comes out four inches there would be considerable tension upon the mesenteric attachment. It seems entirely possible that this phenomenon could be influenced and controlled by the diaphragm and abdominal muscles, and this may be the solution of this unique case. I have never seen a case of this kind.

Epileptiform Seizures in an Infant Aged Ten Months. Dr. J. A. Larrabee: I have been considerably interested and I may say annoyed by a case that has been under my care recently. It is in a family which is decidedly neurotic, and in which there is possibly, without history or committal, a taint of specific disease. It is not very unusual to have epileptic manifestations in children at an early age, but the case I desire to report is, I think, somewhat anomalous. There have been, for a period of fourteen days, eleven petit mal seizures in every twenty-four hours in an infant ten months old. These seizures have not apparently concerned or involved the integrity of the child in any respect. The intellectual functions, so far as intelligence is written upon the face of an infant, do not seem to have been affected. The infant is just as well apparently as if it did not have every hour or so an epileptic convulsion. The attacks present the usual phenomena of true epilepsy. The duration of these attacks is from one to two minutes, accompanied by the usual phenomena, flushing, unconsciousness which is perfect, the attack then passes off and the infant is well again.

108This condition of affairs having been going on for a period of fourteen days in this case without any impairment in the general health of the infant, or in its nutrition, certainly points, I think, to a specific cause. I have often had cases, not quite so remarkable as this, where the tendency has been neurotic or specific in character, which improved under appropriate treatment; but this case has resisted all treatment, even specific treatment by the inunction of mercurials and the administration of the iodides.

The condition is still in progress, the infant having eleven seizures in every twenty-four hours, not exceeding this number and not falling short. I have witnessed several of them, and they are perfectly characteristic of epilepsy. An older child in the family passed through an ordeal of paroxysms, was unable to walk for three years, and this child has been restored under treatment, and that treatment has been antisyphilitic. One child in the family has been lost, and the history is that it died from scorbutus. The family is decidedly neurotic, and I suspect a specific taint.

The case has been exceedingly interesting and even annoying to me because I have been unable to make the slightest impression upon it by treatment in lessening the number or severity of the paroxysms. I am pursuing the same line of treatment that I did in the case of the older child which recovered, and believe I have sufficient ground for specific treatment, but so far it has not been productive of relief.

The peculiarity about the case is that the occurrence of these paroxysms has not so far interfered with the nutrition or the general health of the infant. In this respect I think the case is somewhat remarkable.

Discussion. Dr. T. S. Bullock: I would like to ask if Dr. Larrabee gave the bromides in the case he has reported.

Dr. T. H. Stucky: Have you tried the bromide of gold and arsenic?

Dr. J. M. Ray: In connection with Dr. Larrabee’s case I recall one that I saw several months ago in a child a little older than his which gave a peculiar history. The mother brought the child to me, the history being that the child complained of having something the matter with its ear. I examined the ear carefully. No inflammatory or other disease was present about the structures of the ear; hearing was perfect, and the drum membrane was intact. The child at this time was three years of age. The history that the mother gave me 109was about as follows: The child had never complained of earache; she had never noticed any defect in hearing, but sometimes two or three times a day the child would apparently be interested in her toys or in something about the room, and all at once she would scream and run to her mother and say that the house was turning over, that there was a bug in her ear, etc. This would happen several times a day, and on several occasions the child had fallen over apparently unconscious, or in a state of partial unconsciousness.

After looking into the ear carefully and not finding any evidence of disease, I referred the case to the family physician, and in talking the matter over with him he suggested that these attacks were probably petit mal. He put the child upon bromide of gold and arsenic, and a prompt recovery resulted. The last I heard from the case the attacks were few in number, occurring at long intervals and slight in character, although at one time they occurred two or three times a day.

Dr. T. H. Stucky: I have seen several cases of epilepsy in children, but never saw one in a child so young as that reported by Dr. Larrabee. I have followed out the usual routine, giving bromides and other remedies with varying results; and later, following the suggestion of Dr. Buchman, of Fort Wayne, have tried combination mentioned by Dr. Ray, viz., the bromide of gold and arsenic. I believe the latter to be especially indicated and exceedingly serviceable where we have reason to suspect a taint, as mentioned by Dr. Larrabee, getting as we do the sedative influence of the bromide, the alterative influence of the gold, and also the well-known effects of the mercury contained in the combination.

I believe where anemia is very marked in these cases, and there is a feeble heart action, and we are fearful of the depressing effects of the bromides alone, that in the use of the bromide of strontium and gold we gain a decided advantage, getting as we do the sedative as well as the cardiac influence of the strontium salts. Dr. Marvin demonstrated this conclusively before this society in a statement made by him in regard to the action of strontium salts in digestive disturbances, especially those conditions characterized by marked flatulency. If this be true, and we have reason to believe it is, it appears to me that the bromide of strontium and gold would be even better than the bromide of gold and arsenic in cases such as Dr. Larrabee has reported.

Dr. J. A. Larrabee: The case is reported not to demonstrate any unusual manifestation of epilepsy, but on account of the exact regularity and periodicity of the seizures, and the age of the patient, coupled 110with the fact that the treatment which seems to be indicated has not been followed by relief. In looking up the literature of the subject I find that cases of this character are usually attributed to a specific cause.

In answer to Dr. Bullock’s inquiry: I have used the bromides in this case without any effect whatever. Of course epilepsy in the child is nothing new, but this case presents some peculiarities. There is a decided neurotic tendency in the family, which may have some bearing upon the case. The child is going along having the number of seizures stated each day without any evidence of disturbance of nutrition or impairment of general health, which is rather remarkable. Some of the attacks are almost grand mal, most of them petit mal, and I am convinced that the trouble is due to specific taint.

The next move I make will be to put the child upon the bromide of gold and arsenic.

The Influence of the Organism upon Toxins.—Metchnikoff (Ann. de l’Instit. Pasteur, November 25, 1897,) has applied the method of comparative pathology to the question of the mechanism by which the animal organism prepares antitoxins, and the laws which regulate their production. By growing bacteria and lowly fungi upon culture media containing toxines he was enabled to show that the virulence of the latter was in most cases diminished and sometimes destroyed. In any case these microbes have no influence in the production of antitoxins, and the idea of preparing them by this means must be abandoned. The animal organism alone being capable of producing antitoxins, the next point was to find out whether this was a property common to all animals, or limited to the superior. Metchnikoff found that the injection of large quantities of tetanus toxin into scorpions and the larvæ of other arthropods produced no antitoxin. The toxin remained for months in the blood or tissues without losing its properties; similar results were obtained when it was taken into the alimentary canal of the leech. It was hence shown that even those invertebrates in which antimicrobic phagocytosis is most marked are utterly incapable of producing antitoxins. Coming next to vertebrates, no power of producing antitoxin is possessed by fish or amphibia; it first appears in reptiles, but not in all kinds. Thus tortoises, like invertebrates, can retain tetanus toxin in the blood for a lengthened period without forming antitoxins; it is in reptiles that the production of the latter is first observed, but in them only when they 111are kept at a temperature higher than 30° C. If the temperature is 20° C. the results are just the same as in tortoises and invertebrates. The establishment of the antitoxic property in these cold-blooded animals is not attended with any rise of temperature, and the same is true in warm-blooded animals such as fowls. With regard to the last-named animals, whose power of producing tetanus antitoxin was first demonstrated by Vaillard, Metchnikoff has some new and important observations. He finds that practically all the toxin injected into the peritoneum passes into and remains in the blood, none of the organs being toxic after their blood has been washed out. To this an exception is found in the case of the genital organs, ovaries, and testicles, which possess the power of fixing some of the circulating toxin. This they share with the leucocytes, to the toxicity of which that of the blood is due. After a while the toxic power of the blood diminishes, and after passing through a neutral period it becomes antitoxic. It is now found that with the exception of the generative organs, none of the organs when freed from blood possess any antitoxic power. The genital glands are found to be markedly antitoxic, but the author brings evidence to show that the antitoxin is not manufactured by them, but is absorbed from the blood, so that in the fowl the antitoxic property resides solely in the blood. Metchnikoff concludes that it is not possible to accept the idea that natural immunity depends on antitoxic power, and he further points out that the latter is evolved in the history of the animal kingdom at a much later date than the phenomena of phagocytosis.—British Medical Journal.

The Treatment of Tuberculosis with Tuberculin R.—Dauriac (Progrès Médical, December 4 and 11, 1897,) reports the results of the employment of Koch’s tuberculin R. in various cases of tuberculosis; fourteen of these presented local affections, such as suppuration over the sternum, enlarged cervical glands, ulceration of the skin, etc. All of the patients were satisfactorily cured. In a second paper he describes the results in fifteen cases of pulmonary tuberculosis in various stages of the disease; all were greatly improved, and many are described as cured. One of the cases was insufficiently nourished and clad, had no fixed residence, and, when the treatment was commenced, large cavities were found at the apices of both lungs. A case is also described in which, in addition to pulmonary tuberculosis, lesions were present in the kidneys and the bladder. This patient also made a complete recovery. The treatment, in spite of these brilliant results, is supposed to be most applicable to the earliest stages of the disease, and it is suggested that it would be advisable to detect the presence of tuberculosis by injections of minute doses of the original form of tuberculin. The treatment is usually commenced with a dose of 1
500 mg. This should be increased daily until a dose of 10
500 mg. is reached; this then should be increased 1
50 mg. daily until ⅕ mg. is reached, and this increased ⅕ mg. daily until 1 mg. is given. This can then be further increased if considered desirable, the maximum dose being about 20 mg. The immediate 112effects of the injections are usually nil. With doses in excess of ⅗ mg. a slight elevation of temperature is occasionally observed. Local reaction is extremely rare. The subsequent effects consist in reduction of fever, cessation of sweats, increase in appetite, and disappearance of tuberculous lesions. As none of the patients reported in this paper was admitted to the hospital, but simply came three times or less frequently a week to the dispensary for injections, improvement could not possibly have been due to any alteration in their hygienic surroundings.—The Philadelphia Medical Journal.

Cesarean Section by Transverse Incision of Fundus.—Braun (Centralbl. f. Gynak., No. 45,) has had experience of Fritsch’s cesarean section, the operation being the second of its kind ever recorded. Fritsch bases his practice on the course of the secondary branches of the uterine arteries which run horizontally, so that a longitudinal incision down the front of the gravid uterus can not fail to cause free hemorrhage. He is accustomed to extirpate diseased fallopian tubes completely, snipping a wedge-shaped piece out of the uterine cornu. Bleeding is always free, but the tying of a suture passed antero-posteriorly under the bleeding vessel stops it at once. The ligature lies at right angles to the vessel, the most favorable position. Hence Fritsch conceived the idea of making an incision straight along the fundus from cornu to cornu, in order to extract the fetus in a cesarean section. Braun publishes full notes of his own case. The patient was a rachitic primipara with a universally and irregularly contracted pelvis. The conjugata vera was two and three-quarter inches. Labor pains had set in. Care was taken to antevert the gravid uterus sufficiently, the upper part of the wound being held together with forceps during delivery of the child. Then the transverse incision was made. Braun found that it bled as much as the longitudinal incision in cesarean sections where he had operated during labor at term or in relatively early pregnancy. The placental site did not lie near the fundus. The delivery of the fetus, which was living and weighed six pounds, was neither harder nor easier than through a vertical incision. The wound in the fundus was under four inches long after the fetus had been extracted. The sutures had to be placed close together, fifteen deep and eight superficial being applied. Ergot was given after the abdominal wound was closed, as there was hemorrhage. The patient made a good recovery.—British Medical Journal.

Labor in Mature Primiparæ.—De Koninck (Revue Medicale, Louvain, October 30, 1897,) has compiled an instructive memoir on labor in primiparæ married for some years and relatively mature (twenty-eight years Bidd and Pourtad, thirty-two Ahlfeld). De Koninck gives thirty as the earliest year coming under “maturity,” the “primipares agees” of French authorities. He sets aside as curiosities certain cases of primiparæ almost “aged” in the English sense of the term, such as Cohnstein’s two women aged fifty and 113Steinmann’s woman aged fifty-two. It appears that in a genuine uncomplicated case of delayed impregnation the advent of the catamenia is always found to have occurred late in youth. Out of 401 such cases menstruation was retarded till twenty in 39, till twenty-four in 4, and till twenty-six in 1. As to the retarded first pregnancy, abortion, ectopic gestation, twins, and special renal mischief are relatively frequent. Above all, lingering labor is specially common, statistics even exceeding guesses and a priori reasoning in this respect. In 12 out of 17 noted by De Koninck labor lasted from forty to fifty hours, the remaining labors being yet longer; 1 exceeded ninety hours. Feebleness of uterine contraction is absolute from first to last, and independent of any obstetrical combination. They also cause far more physical and mental exhaustion than the vigorous contractions of a young uterus, and at the same time are more painful. There are discrepancies in the “pains” seen in mature primiparæ of the same age, probably homologous with the great variations in the age of menopause observed in otherwise normal women. The uterus may be older in one woman aged thirty-five than in another of the same age. The forceps and other obstetrical operations are often required in the mature. Most of the above facts are easily explained. The excess of male infants borne by mature primiparæ (thirty per cent) is a less explicable phenomenon. Hecker considers the predominance of male infants as a speciality of all primiparæ, but Rumpe turns attention to the fact that in a family of children the predominance of males is commoner the further the mother is from her first menstrual period.—Ibid.

Kinesitherapy in Heart Disease.—Colombo (Gazz. Med. di Torino, 48, N. 39, 40, 1897,) pleads for a more general use of kinetic treatment in heart disease. Even in advanced cases he seems to think such treatment is very advantageous. Milder forms of treatment, for example, the Swedish method of gymnastic exercise, should be started at first, and afterwards more active methods, for example Oertel’s, can be tried. The action of the Swedish method is most marked upon the peripheral vessels, while Oertel’s system acts more directly upon the heart itself, so that dividing heart disease into disease of central or cardiac, and that of peripheral or vascular origin, the different methods could be applied accordingly. The Swedish method, moreover, has this advantage, that it can be applied in severe cases which can not leave their beds. Barie (Sem. Med., November 12, 1897,) advocates the treatment of heart disease by Swedish gymnastics. The aim of the exercises is to facilitate the work of the heart by increasing its contractile power and by lessening the peripheral resistance. The exercises are a series of regulated, combined, or alternating movements of resistance or opposition. The movements employed fall under the main groups: (1) Kneading, rubbing, or stroking of the muscular masses in the limbs and abdomen; (2) movements of circumduction which facilitate the circulation in the main venous trunks; (3) movements which favor respiration. The exercises are very varied, and accomplished by means of passive and active 114movements, numerous different manipulations, and by special apparatus. The average duration of the treatment ought not to be less than an hour a day during three months of each year. The treatment is suitable for cases of dilatation, hypertrophy, fatty degeneration, chronic myocarditis, and various neuroses and functional affections of the heart. Such symptoms as shortness of breath, palpitation, insomnia, cephalalgia, giddiness, gastric phenomena, edema, ecchymosis, cyanosis, improve or disappear under treatment. The pulse-rate is lowered, but rises again as soon as treatment is interrupted. Rational application of the treatment does not exclude internal treatment by ordinary medical means, and the two methods may often be employed simultaneously with the best results.—Ibid.

Live Frogs as an Antithermic.—An English practitioner of Constanta, Roumania, writes: On the evening of October 19th I was called to visit a Roumanian boy, six years old, suffering from typhoid fever. I found him in extremis, almost pulseless. The child’s head was completely wrapped over with a large white sheet, and as I looked at it this enormous white envelope seemed to be on the move, and while I was surveying this covering there crept from under it a small frog, which quietly sat over the child’s left arm. It seemed quite content. I immediately called the mother’s attention to it and requested her to take the animal away, thinking it had crept there as an intruder. “Oh, no!” said the old lady, “a doctor recommended that a lot of them should be kept to the head to keep it cool.” Seeing the head covering still on the move, I raised it for curiosity, and in a second out jumped about twenty other frogs and hopped away in all directions. I have often heard the expression “as cold as a frog,” but this was the first time I had seen a frog applied as a head-cooler.—London Lancet.

Treatment of Endometritis in Bromine Vapor.—Nitot (La Gynecologie, October 15, 1897,) maintains that the correct prophylactic treatment of parenchymatous metritis and chronic salpingitis consists in rapid cure of recent endometritis, which is the starting point of those troublesome diseases. To insure cure a remedy is needed which can penetrate to the deepest recesses of the muscosa, and even the tubes, without dangerous effects. Caustics and fluid preparations do not possess such properties. A gas is required, and it must be freely diffusible, antiseptic, and capable of acting on the epithelium so as to modify without destroying them (“anticatarrhal action”). Bromine emits gas with the necessary qualities; a saturated aqueous solution should therefore be placed in a bottle with double tubing like an ether spray or the chloroform bottle in a Junker’s inhaler. A hollow sound, connected with one tube, is passed into the uterus, while the solution is made to bubble by pressure on a ball connected with the second tube. Thus vapor is propelled into the uterus. Nitot claims the best results, and notes that the advantages of gaseous diffusion over intra-uterine injections or other medication are self-evident.—British Medical Journal.

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The New York Post-Graduate Clinical Society^[2] was recently treated to a moving discourse on the novel subject of “The Art of Neglecting Wounds,” by Dr. Robert T. Morris, one of the instructors in surgery in the Post-Graduate School.

The author confined his remarks to wounds made by the surgeon when operating, and hints pretty strongly, though he does not say so, that their subsequent treatment even by the surgeon himself might not inappropriately be called “meddlesome surgery.”

For instance: In incised wounds (the margins of which have not been quite approximated) the capillaries begin to develop granulation tissue in the coagulated lymph deposited upon the surface in a few hours if the trophic nerves have not been much injured. This granulation tissue is extremely delicate and will not bear handling. When such a wound is suppurating freely the strong temptation to wipe away the pus with sponge or gauze should be resisted for two reasons, first, “Granulation tissue suffers traumatism whenever it is touched, no matter how lightly, and, as a result of such traumatism, there will be developed exuberant granulation tissue, which will be poorly supplied with blood-vessels. We have in weak granulations, so to speak, what might be called ‘watered stock.’ It is a very common result of our well-intentioned but ill-directed efforts at keeping the wound clean.”

Gauze upon the granulations will injure the tissue still more, since its filaments entangle the granulations, which on removal of the dressing 116are broken off in small fragments. The device which prevents this injury is a covering of very soft gutta-percha tissue or Lister’s protective silk. But the surgeon who practices this let-alone method, though backed by sound pathological knowledge and therapeutic principles, will not escape the censure of the family or the nurse, and too often allows his sense of neatness to take precedence of his more sober sense founded upon pathological knowledge.

This “neglect” is particularly desirable when epithelium is shooting across the wound. These hyaline cells are so extremely delicate that the slightest touch will damage or remove them to the detriment of the healing process. The dressing on a suppurating wound should be allowed to remain five or six days. Though the ignorant may find fault with the surgeon for such temporizing, he must insist upon it for the patient’s well-being.

Another illustration is drawn from the operation for appendicitis, in which we have adhesions, pus, and wide infection. Here new pathological factors are met with. The peritoneum throngs with polynuclear leucocytes which are engaged in destroying the bacteria. If time be given these faithful guards to mass themselves in the peritoneal lymph channels, they will prevent the extension of the peritonitis from this point. The surgeon, having evacuated the pus, removed the appendix, and inserted the drainage apparatus, is tempted, because of its bad smell, to wash out the wound. Such a measure would not only give the patient detrimental annoyance, but would inflict a new traumatism upon the tissues. “This traumatism calls out an unnecessary number of leucocytes, and an unnecessary degree of reactive inflammation ensues. If, on the other hand, the colon bacilli are allowed to increase, they will at first produce a very foul odor to the discharge, but in three or four days we will usually find streptococci abundant, and perhaps displacing all other bacteria.” In such cases, leave the drainage apparatus in place and “neglect” the wound. “Repair and destruction of bacteria will go on much better if we leave the wound alone, after having removed the principal mass—the contents of the abscess cavity.”

Another illustration is found in burns of the second degree. Here large blisters have formed and broken, and much skin is denuded of its cuticle. In such a case the author administers an anesthetic, opens the blebs, removes the detached skin, scrubs the parts with an antiseptic solution, covers the denuded surface with strips of gutta-percha tissue, and leaves the case to nature. When a change is made, it 117should be of the outer dressings only. And the reasons for this treatment are that in such burns “the serum which is thrown out is germicidal, and is destroying all the bacteria upon the skin very rapidly. This germicidal action will go on so long as the serous exudation is free, but when the coagulation of lymph begins on the surface, this action becomes very much diminished, and the bacteria are then liable to liquefy the lymph and grow very rapidly, as new portions of serum are thrown out. This leads to sepsis and sometimes to the formation of thrombi, with necrosis of the duodenum and perforating ulcer. The patient’s friends complain if the dressings are left long in place, and yet I know of no wounds which do so well when ‘neglected’ as burns.”

In the discussion that followed, the author, being asked what he would do with suppurating sinuses, said “he knew of sinuses that had been kept open week after week and month after month, and had proved veritable gold lodes to the surgeons. If the surgeon had been compelled to go away for a time, these sinuses would have healed long before they did. This might seem like a joke, but it was a fact with which he was brought face to face all the time. His rule was to leave sinuses alone, in the belief that the poorly fed granulations lining them would in time cause approximation of the walls, and healing would occur. It was true that exceptions would have to be made for some sinuses, but that did not affect the rule as given.”

Such considerations give accentuation to the dictum of Velpeau, that “nature is a good physician but a bad surgeon,” and dignify the bon mot of Holmes, who, seeing the smoothly healed and finely cushioned stump which resulted in time after an amputation, exclaimed:

For the surgeon’s far more than the physician’s successes depend upon the vis medicatrix naturæ, and he who is best versed in physiological and pathological processes, and administers the surgical art accordingly, will secure the best results.

They who neglect their surgical cases from ignorance, carelessness, or a wanton disregard of the great pathological dicta of the day, can find no justification in these teachings, for the truth, as embodied in the author’s closing words, puts all such to shame and confusion: “A good deal of skill is required in order to neglect wounds well. This ‘neglect’ of course implies a proper understanding of the processes with which one is dealing.”

On the 25th ultimo this accomplished physician and estimable gentleman died at his home in Farmdale, Ky. He had been in failing health for something more than a year. His ailment was Bright’s disease, and the end was precipitated by uremia.

Dr. Stewart was born near Louisville, Ky., in 1829. In 1849, having secured a good common school education, and graduating in law, he went to the gold fields of California, where he sojourned for seven or eight years. Returning to his native State, he entered upon the study of medicine, and graduated from the Kentucky School of Medicine in 1859. He began practice in Daviess County, Ky., but after a few years moved to Owensboro, where a larger field of usefulness and fuller success awaited him.

In 1878 Dr. Stewart was called by Governor John B. McCreary to the position of Medical Superintendent of the Kentucky Institution for the Training of Feeble-Minded Children. It was here that the chief work of his life was done. And it was here that he served humanity and the State with honor, with ability, with fidelity, and with an earnest, self-sacrificing devotion to the welfare of these rejected waifs of humanity which entitles him to place and rank among the higher philanthropists of our philanthropic profession.

In the care of the feeble-minded Dr. Stewart added to his executive work the habits of a careful student, and became one of the best known alienists of the land. His address as retiring President of the Kentucky State Medical Society in 1894 was an able and scholarly treatise upon the management of the feeble-minded. It was received with great favor by the Fellows, and has since been the subject of high encomiums from doctors, lawyers, and political economists.

After sixteen years of State service Dr. Stewart purchased the old Kentucky Military Institute near Frankfort, where he established the “Stewart Home for the Feeble-Minded.” The venture was successful beyond expectation, and here in the bosom of his family he passed serenely and blissfully the closing years of his gentle, useful, and beautiful life.

Dr. J. Q. A. STEWART.

The Surgery of the Thyroid from a Neurologic Standpoint.—In a suggestively written paper in the January number of the American Journal of the Medical Sciences, Dr. J. J. Putnam uses the following words: “We are rather in the habit of assuming that the removal of large portions of the thyroid does no harm, provided it does not cause myxedema. But the probability is that we shall learn to recognize affections which lie between myxedema and health, as well as peculiarities of development and disorders of nutrition for which the thyroid is more or less responsible.” ... That this is a statement of fact will hardly be disputed by any neurologist, but that it expresses a truth that has as yet been insufficiently impressed on the profession generally is another fact the importance of which is not likely to be overestimated. It is only within a comparatively brief period that we have learned that the thyroid had any definite function and our knowledge of its physiology is still very far from being exhaustive. The dangers also of interference with it are as yet also only partially known, but it is certain that they are not confined to the operation itself. The cases of sudden fatal dyspnea occurring hours after an apparently prosperous operation in Graves’ disease, recently reported by Debove and others, are in evidence of this, and Dr. Putnam adduces other important facts and arguments against any too venturesome surgery of the thyroid gland. Among these are the experiments of Halsted, showing that excision of the gland in dogs had a serious and very evident disturbing effect upon their offspring, and that even very slight operative interference produced hypertrophic changes and apparent increase of secretion in the gland itself; and the observations of Kocher of goiter and cretinism inherited from parents with no disease other than impaired thyroid function are also cases in point. Still another fact brought forward by Putnam is the one that removal or atrophy of the thyroid in infancy checks the growth and function of the reproductive organs, and gives rise to the various disturbances of development that follow the suppression of this very important function. The close relations of the various internally secreting glands, the thyroid, the testicles and ovaries, the suprarenal glands, and the pituitary body, for this it seems probable must be included in this category, are revealed in many pathologic conditions, and the thyroid as the largest, and presumably the most important, has apparently a larger part in the disturbances than any of the others. It seems to be involved to some extent in many cases of acromegaly; its relations with the genital development have already been mentioned, and its implication in many pathologic conditions of organs is probable and is strongly suggested by 120the clinical history in certain cases of Graves’ disease. Seeligmann has indeed recently reported a case of this affection apparently closely associated with genital disorder in which he obtained decided benefit from the administration of ovarian extract, thus adding another suggestion to the therapeutics of the disorder.

When any organ is removed, as Putnam says, two factors are set in operation which may have more or less important effects upon the system generally. One of these is the action of toxins, the other is the effort of the organism to adapt itself to the new and changed conditions. The first of these is important enough in the case of removal of the thyroid gland, but the other, from what we are beginning to know of its physiology, must be even more important. Because the function of the organ is already deranged, it does not necessarily follow that matters will be remedied by its removal. The operation may only make a bad matter worse. The mortality of thyroidectomy, according to Poncet, is from fifteen to thirty per cent, which is alone enough to induce caution. When the facts brought forward by Dr. Putnam are also considered, the known and the possible and hinted though yet unknown effects of thyroid ablation, there is still more reason for prudence and hesitancy in this operation.

Of course when a goiter has become a dangerous mechanical embarrassment to important functions, or when a tumor exists in the thyroid that by its growth and situation has become a threatening danger, the case is clear, and operation may not only be justifiable but necessary. It is in such affections as Graves’ disease, in which thyroid operations are still somewhat popular, that we are likely to have not only useless but dangerous surgery, and the time seems to have come to emphasize the cautions implied in Dr. Putnam’s paper. The theory of hyperthyroidization in this disease, though it has apparently much in its favor, is not yet sufficiently demonstrated, and even were it so, would not form a justification for any indiscriminate or frequent practice of operative interference. Graves’ disease is not by any means a hopeless disorder under medical treatment, even in its advanced stages; it is therefore impossible to say when surgery is indicated as a last resort. When the facts of its absolute inefficiency in perhaps the larger proportion of instances in which it has been tried, the immediate dangers of the operation which are not slight, and the remote ones pointed out by Dr. Putnam, are all taken into consideration, it would seem that it ought to be relegated to innocuous desuetude.—Journal of the American Medical Association.

The Treatment and Prognosis in Graves’ Disease.—This short article is prepared solely with the view of eliciting from medical men who have met with cases of exophthalmic goiter in their practice, the results of their observations regarding many points of interest in connection with this curious disease. I do not intend to give a systematic description of the affection in question. This can be found in any good modern text-book. 121Described many years ago by Parry, Basedow, and by others more recently, it is much better understood and more widely known than formerly.

Opinions differ radically as to its real nature. The best modern authorities regard it as a pure neurosis, and functional only in character, although organic changes often develop during its course in the heart, thyroid gland, and elsewhere. Some still speak of it as due to changes in the medulla oblongata; others again look upon functional and structural changes in the thyroid gland as the real cause of the malady. My own experience inclines me to view it as a neurosis pure and simple, although marked and characteristic structural changes supervene during its course, and may become permanent. Probably in the near future we shall learn more as to its exact nature. Already it is satisfactory to note that cases are far earlier and more frequently recognized, and that their treatment is more successful.

From their first appearance its special features attract attention. These are few in number, and easily borne in mind: 1. An unusual and more or less constant rapidity of the heart’s action; 2. The early presence of more or less protrusion of the eyeballs; 3. A marked enlargement of the thyroid gland; a tendency to tremors or tremblings under very little, and sometimes no excitement, although this always increases it. It is not surprising that these indications of exophthalmic goiter which develop more or less rapidly and become often most distressingly marked, should cause much anxiety to the patients and their friends, as well as to their medical attendants.

With regard to the duration of ordinary chronic cases (for acute ones are seldom met with), what has been the experience of those who may read this article? I have never met with an acute case, but have seen months and one or two years pass before there was more than a partial improvement.

One case, a very bad one, in which the patient’s circumstances were so poor that she worked on during her illness, when she should have had care and rest, recovered completely. But so serious was this case, that the sight of both eyes was entirely lost from the excessive protrusion of the eyeballs during the disease. When I first saw her, which was years after her recovery, the story of her case was intensely interesting, but most sad.

Then as to the frequency with which relapses occur in this disease, it would be interesting to get the experience of good men. Many speak of relapses being frequent, even after apparently complete recovery has taken place. Others think them not of so common occurrence.

There are also many points of great interest in connection with the prognosis. One of these is the probability of the recovery being perfect. My own experience has been that the lighter or milder the case the greater the probability of a perfect cure.

Another matter of interest is in connection with cases in which the symptoms greatly abate, the health indeed appearing to be perfectly 122restored, but in which the exophthalmos and thyroid enlargement continue noticeable; whether in such patients very slight causes may not lead to a return of the disease. From what I have seen, the conclusion appears correct, that provided the heart’s action is normal as to frequency, and not too easily disturbed, these cases are not specially likely to have a second attack, which is tantamount to saying that, provided the heart’s action has become normal, any other relic of the illness is comparatively unimportant.

I have observed, too, more or less scleroderma present when the attack has not been by any means of a serious character, and when afterward the general health became all but perfectly restored. This is an interesting concomitant. It would be desirable to have others give their experience as to its occurrence in cases they may have attended.

Then as to the effects of pregnancy during the course of the disease; some high authorities speak very strongly as to its great danger. Others remark that the affection has improved during gestation. This is another matter on which fuller information would be most useful.

As to the percentage of fatal cases, this is hardly as yet to be determined so as to be useful to the practitioner. My own cases have led me to the conclusion that every particular case has to be regarded per se, that is, if the symptoms are light and comparatively trifling, and show signs of abating, the prognosis is favorable, while under an opposite state of things it is the reverse.

As to treatment, what has succeeded best in my hands has been enjoining upon patients the necessity of a great deal of physical rest, at least ten or twelve hours a day if possible, and the avoidance of all mental worry. On this, great stress should be laid. These patients require abundant nourishment. Galvanism in my hands has been found most useful; employed twice a day and so applying the poles that the current may go from the back of the neck through the thyroid gland, and the heart, and even (the current being made very weak) through the eyeballs. This current has been continued for months, and in some cases for a year and a half, with good effects. Sometimes tincture of digitalis has been useful in moderate doses, ten or twelve minims three times in twenty-four hours, in some cases, and useless in others. Iron has been found of great value and persisted in for a long time. As a nerve-tonic, strychnine in small doses has been exceedingly beneficial. Quinine, if used, should, unless malaria complicates the case, be used in small doses only, such as 1½ grains three times a day, with the iron and strychnine.

I know that many of the matters I have mooted in this paper have been quite recently discussed by Drs. Ord and McKenzie, of London, in an excellent article on exophthalmic goiter in the fourth volume of the new System of Medicine edited by Allbutt, but a still wider discussion on the matters alluded to, and on many others, by practitioners who have met with and treated such cases, will do much good, and tend to make the care of such cases more pleasant and the results of treatment more satisfactory. Walter B. Geikie, M. D., C. M., D. C. L., in Philadelphia Medical Journal.

123Dangers of the Nasal Douche.—Lichtwitz (Sem. Med., November 26, 1897,) deprecates the routine prescription of the nasal douche in all cases of hypersecretion of the nasal mucous membrane. Irrigation is called for only when the nasal fossæ require clearing of pus and crusts, for instance in idiopathic ozena. This affection is mainly limited to the nasal fossæ properly so called, and irrigation is in such a case the most fitting form of procedure. An ordinary syringe or enema syringe with suitable nozzle should be used. In all other nasal affections irrigation is inadequate or useless; it is even dangerous. Repeated flooding of the mucous membrane may give rise to olfactory lesions. Antiseptics are highly injurious and pure water is badly borne; the physiological solutions of sodium chloride, sod. bicarb. or sod. sulph. are the only harmless liquids. In numerous cases irrigation has caused the sense of smell to be temporarily or permanently diminished or lost. Distressing frontal or occipital headache may result owing to the liquid passing into the sinuses. The injection of irritating liquids may even set up inflammation of these cavities. The most skilful and careful irrigation is insufficient in many cases to prevent the resulting headache. A very grave complication is the penetration of the liquid into the middle ear, suppurating otitis media occasionally supervening. In acute coryza, especially in children, douching should never be practiced. In one such case known to the author mastoiditis followed irrigation of the nasal cavities. The predisposition to otitis is increased after retro-nasal operations, in particular after ablation of adenoid vegetations. For eight years the author has given up all irrigation after pharyngo-tonsillotomy, and during that period has met with no case of post-operative complication.—British Medical Journal.

Antipyrin.—In July of this year the antipyrin patent, held by the Hochst color-works, will expire by limitation, it having run its course of fifteen years—the span of life allowed to a German patent. During these fifteen years the monopolists have sold the drug at about $12.50 a pound, but it will, of course, fall considerably in price the moment the manufacture and sale are permitted competitors. It is anticipated that it will shortly fall to at least half its present price, when the usual convention of the principal competitors will be called and the inevitable trust formed, leading to a consequent rise in price. It is rumored that a number of chemical works are busy with the manufacture of antipyrin, so as to be prepared with it immediately upon the expiration of the patent.—Philadelphia Medical Journal.

Professor Robert Koch has been invited by the Indian Government to make another stay in India for the purpose of studying the epidemic and endemic diseases of man and beast so prevalent there. Koch is now engaged on work that will keep him in German East Africa for some time, probably about a year, and does not think of leaving until he has concluded it.

Rheumatoid Arthritis.—Rheumatoid arthritis is a chronic progressive disease with an almost hopeless prognosis as regards a complete cure. The most that can be hoped for is to arrest its progress for a longer or shorter time, and to render the patient’s life more tolerable by improving his health and relieving the pains in the affected articulations. Galvanism, massage, baths, and an invigorating diet have been found of more or less value, as well as the administration of cod-liver oil, ferruginous preparations, and the iodides. A comparatively new remedy that seems to have a promising future before it in the treatment of this disease is Lycetol. Judging from the observations thus far published its use in rheumatoid arthritis is capable of effecting considerable improvement. One of its distinct advantages is that, owing to its pleasant taste and freedom from irritating effects, its administration can be kept up for a long time, a point of great importance in the treatment of chronic affections, in which remedies must be given for a prolonged period before beneficial results can be expected. In two cases recently reported by Dr. Paul Norwood (Times and Register, November 6, 1897), one being a very bad one of chronic rheumatoid arthritis, the results were very encouraging. A slow but steady improvement occurred in the second case, while in the first the patient provoked a recurrence by discontinuing the treatment. In view of the obstinate character of the affection and its resistance to the remedies heretofore in use, Lycetol should be certainly considered an eligible remedy in these cases.

Meeting of American Medical Publishers’ Association.—The Fifth Annual Meeting of the American Medical Publishers’ Association will be held in Denver, on Monday, June 6, 1898 (the day preceding the meeting of the American Medical Association).

Editors and publishers, as well as every one interested in Medical Journalism, cordially invited to attend and participate in the deliberations. Several very excellent papers are already assured, but more are desired. In order to secure a place on the program, contributors should send titles of their papers at once to the Secretary.

Obstinate Constipation.—I used Chionia, a teaspoonful three times a day and at bed times, in a case of long standing obstinate constipation. The first three nights I directed a hot water enema to be given every night. This treatment brought about regular and spontaneous evacuations, and resulted in a complete cure.

The phosphates of iron, soda, lime, and potash, dissolved in an excess of phosphoric acid, is a valuable combination to prescribe in nervous exhaustion, general debility, etc. Robinson’s Phosphoric Elixir is an elegant solution of these chemicals. (See advertisement.)

LABOR SAVING: The American Medical Publishers’ Association is prepared to furnish carefully revised lists, set by the Mergenthaler Linotype Machine, as follows:

List No. 1 contains the name and address of all reputable advertisers in the United States who use medical and pharmaceutical publications, including many new customers just entering the field. In book form, 50 cents.

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List No. 2 is furnished in gummed sheets, for use on your mailer, and will be found a great convenience in sending out reprints and exchanges. If you do not use a mailing machine, these lists can readily be cut apart and applied as quickly as postage stamps, insuring accuracy in delivery and saving your office help valuable time.

These lists are furnished free of charge to members of the Association. Address Charles Wood Fassett, Secretary, cor. Sixth and Charles streets, St. Joseph, Mo.