He had been told that life insurance companies find that the majority of cases with high arterial tension in which albumin is present in the urine even in small amounts for a long time develop fibroid kidney.

Dr. Gray, in closing the discussion, stated that he was ready to believe that small quantities of albumin found persistently in the urine may lead to arterial fibrosis and cardiac hypertrophy, and in the course of time to evidences of renal disease. He had been examining these cases carefully for two years, and could turn to cases of neurasthenia more or less improved which have been under observation for fifteen years. Neither in these latter cases nor in those occurring in the last two years had he ever seen an undoubted development into renal disease. Again and again he had had urine examined by the nitric acid test and have found no traces of albumin, but noting something suspicious about the specific gravity, he had had urine examined by Millard's test, and have found a trace of albumin. On the other hand, he never saw a case show albumin with nitric acid which did not show it with Millard's test. When he began these examinations he found that he had much to learn about detecting small traces of albumin in a test-tube. He could recall 1,100 cases which had been tested by these methods, and on this experience he based preference for Millard's test.

PERICARDIUM WOUNDS.-Dr. Amerio reports ("Med. Rec,") a wound of the pericardium, the heart having escaped. The most prominent symptoms presented by the patient were dyspnoea, small, rapid, and irregular pulse. From two of the seven wounds in the precardial region pericardial fluid mixed with blood issued, and percussion showed an increased cardiac area and pneumo-pericardium. Treatment consisted in enlarging the wounds, disinfecting the pericardial cavity, and then closing the wounds with an antiseptic dressing. Dr. Amerio cites similar cases in literature, and instances of puncture or incision into the sac in certain forms of pericarditis. He made numerous experiments on rabbits, making in some cases a simple incision into the pericardium, in others practicing a partial or total ablation of the sac. Except for two cases, in which death occurred from infection independent of the operative procedure, all the animals survived the infliction of the trauma. The following were his conclu

sions: Animals may live in apparent health even after wounds which have resulted in complete pericardial adhesions. Pericardial surgery

should be further developed, so as to render certain the prevention of septic infection and of wounds of neighboring organs. Where it is certain that the pericardium has been wounded, especially if the lesion has been made with septic instruments, surgical intervention is justifiable; it should consist in enlarging the pericardial wound, washing out all blood and pus from the sac, and thoroughly disinfecting it. In certain thoracic tumors which have invaded the pericardium, the affected portion of the sac can be removed without prejudicing life.

CAFFEINE IN PEDIATRY.-Dr.Brunead advises the use of ("Sem. Med.") the following in cardiac weakness after acute disease in childhood:

CAUSES OF HEPATIC COLIC.-M. Lépine combats the usual theory that hepatic colic is always dependant on foreign bodies in the bile ducts ("St. Louis Med. and Surg. Jour."). He believes that it may be due to simple spasms; and he bases his theory on three grounds. First, clinical proofs: hepatic colic is common in cases of hysteria where no gall stone is present. He has also seen hepatic colic provoked by eating of certain foods. Second, proofs from pathological anatomy: in 1892 ("Revue de Méd.") was published an autopsy in jaundice accompanied with colic, where the only lesion found was the contraction of the bile duct, which was patent and contained but a few grains of gravel. He had a case where it had been necessary to puncture the gall bladder. This was followed by jaundice, which persisted up to the moment of death. At the necropsy it was found that the common duct had been punctured, cicatrization and contraction had taken place, though there was no complete obliteration; colic had been present during life. Third, experimental proofs: spasm of the lower part of the common duct can be set up in dogs, and Doyon has proved that reflex condition of the bile ducts can be excited by influences having their origin in the stomach.

9

He

The first element in the treatment is a physical one of the chiefest importance. The patient must be placed in a large, light, and well ventilated room; the end room of the apartment is to be insisted upon; the one in the rear end of the house is to be preferred. The bed ought to be narrow, bedding firm yet soft and smoothly drawn, the covering just sufficiently heavy to protect the body. If two beds can be procured the better, as the bedding ought to be changed daily. The patient himself must be kept absolutely quiet; this means that the bed-pan must be used to relieve the bladder and rectum. had better be fed and have all things handed him. Sponging with tepid water to which alcohol has been added is to be performed twice daily, and in such manner that only one part of the body is moistened and dried before another is wetted. The skin over the bony points should be painted over with an alcoholic tannic-acid solution so as to harden the skin, in this way forestalling any possible bed-sore. A mouth-wash must be frequently used during the day. This condition of quietude must be continued in for seven days after defervescence, although I have allowed an intelligent patient, after a moderately severe attack, to rest in an easy chair for an hour on the fourth day after normal evening temperature without untoward results; but this would allow the majority of patients too much liberty.

On medicinal treatment of the patient there exists much disagreement among physiciansthere being all grades of treatment from giving practically nothing to very extensive medication. If the patient be seen early in the disease a single dose of calomel of 10 grains is administered late at night, and if no evacuation has taken place this is followed by a dose of magnesia (citrate or sulphate) in the morning. This removes useless deleterious intestinal contents, such as fæces, undigested and fermenting foods, ptomaines and leucomaines. It may act as an antiseptic directly in its own form, but it most certainly has an indirect antiseptic action in so far as it stimulates a more active secretion from the liver and alimentary glands, and thereby assisting the digestive function. This is, in all *N. Y. Acad. of Med. Trans. Cond.

probability, the explanation of the fall of bodily heat after the administration of calomel and similar cathartics. Typhoid fever being a disease in which the lesion is a congestion and ulceration of certain portions of the intestinal tract, it might be considered a surgical disease; and, as in surgery, the object is to keep wounded and exposed tissues in an aseptic condition, so it must necessarily be in the treatment of typhoid ulcers, but this can only be done indirectly. Only such matter can come in contact with the ulcerated surfaces as enters the system, or is secreted by the alimentary tract and ulcers themselves, consequently the only treatment which will avail any good results is such a one as will in the first place prevent the introduction of deleterious foods and drinks, and, secondly, such treatment as will call forth an active and normal secretion of the various juices as they are secreted in health. In this way the amount of effete material will be lessened, thus resulting in less absorption of poisonous matter, followed a lower grade of fever. To accomplish this has led to the administration of nitro-hydrochloric acid and dilute hydrochloric acid, with or without pepsin, to aid gastric digestion, and fel bovis inspiss. to complete digestion of the intestinal

contents.

These drugs have been used in preference to the so-called true antiseptics, as salol, carbolic acid, and iodine, etc. (creolin, salicylic acid and its derivatives, and creasote), as the latter remove the results and not always prevent the production, whereas the former prevents the production of unnecessary poisons. The violent headache, the delirium and restlessness, I have best relieved by application of cold to the head. Seldom have I used the bromides, which seem to be the best of all sedatives. The diarrhoea, which in some cases was excessive, I have found to moderate after the use of the above-mentioned drugs; likewise those cases in which constipation was apt to occur, were relieved by the same drugs. Excessive tympanites never occurred in my cases. Intestinal hæmorrhages were treated with absolute rest, even avoiding the use of the bed-pan for hours, ice bags to the abdomen, and injections of ergot and morphine. Perforation never occurred in any case in private

practice; if such should occur I would call upon an experienced laparotomical surgeon to consider operative procedure.

Hyperpyrexia is probably the symptom to which most attention has been and probably will continue to be paid. A degree of bodily heat exceeding 104° may be considered hyperpyrexia. I hope to hear very extensive and instructive discussion upon the symptom and the various methods of its combatment, such as cold bath, pack, antipyretics, etc. Among my own cases there have been some that ran as high as 105°, yet with the methods pursued the same had been reduced to 103° and less. If in any future case the temperature should remain high with much restlessness, accompanied by a dry skin, I would most diligently apply sponging with tepid water to which alcohol has been added, with an ice bag to the head, and only in very obstinate cases and in such in which I saw the patient was suffering because of the increased fever, would I resort to any of the coaltar products, or to the bath, gradually cooled down, after previously stimulated the patient.

Whether or no stimulants should be used I have seen fit to answer in the affirmative, and for the following reasons. First, the disease is a prolonged and exhausting one, and, secondly, during the long night hours or between visits a sudden and alarming collapsed condition can develop which may not be recognized in time by the nurse. I prefer stimulation with the milder alcoholics at first, at present using a wine combined with nutritive substances as is to had in the liquid beef peptonoids. In severe cases of typhoid, whisky in liberal quantities is used: of drugs I depend upon strychnine and caffeine, for active and quick stimulation upon ammonia, and for hypodermatic use upon camphor, ether, and alcohol.

As regards the diet of the patient I depend chiefly upon boiled milk, attempting to give at least 1 to 2 quarts in 24 hours, depending upon the digestive capacity of the patient, also a liquid beef extract as Valentine's, Bovox, Bovinine, or a solid extract as Rudish's, Armour's, or Liebig's. There may not be any difference in the nutritive value between the different preparations, but I have found that some patients will relish one in preference to another; broths, and eggs beaten up in beef teas. Thus obtaining a high degree of nutrition with a small quantity of waste, and thereby having a minimum amount of irritating material passing over the ulcerated surfaces. As

soon as the fifth day after a normal evening temperature I have allowed scrapped beef in small quantities with impunity. To recapitulate, in short:

If a case is seen early, I give 10 grn. of calomel. Then follow with the routine treatment, which consists in the administration of NHCl or HCl at stated times, and in the intervals water aciduated with these acids to quench the thirst, and capsule containing 2-4 grs. of fel bov. 3-6 times a day, combining with this nux vomica, caffeine, and quinine in small doses as the special case requires. The complications and sequelæ to be treated independently. In the use of the fel bov. it is essential that a good quality be employed, and the purified extract should always be insisted upon. An impure product will act as an irritant, and cause vomiting, intestinal colic, and diarrhoea.

In the discussion Dr.W. H. Thompson said that while the present treatment of pneumonia gave no better results than those of four decades ago the case was very different. The first indication for treatment is to prevent starvation. Typhoid fever exerts an especially destructive action on the peptic power of the stomach. In no wasting disease except gastric cancer itself is the peptic power of the stomach so diminished as in typhoid fever. Therefore begin treatment with the idea that the digestive power of the stomach is no better than that of a new-born infant. Have the milk given the patient diluted to the same amount that it would be for an infant-that is to say, diluted half with lime water. Lime water is no mean antiseptic, and it assists the digestion of casein. He secured artificial digestion by giving eighty grains of pepsin in the twenty-four hours. The next indication is for the use of bismuth. As a routine measure at the beginning, he gave calomel ten grains, and compound jalap powder thirty grains. Often if diarrhoea be present, this will check it. Ten grains of bismuth should be given every three hours. This prevents the fermentation that causes tympanites. Beyond this, ery little medication is needed. When the tongue is dry and tremulous, there is advanced intestinal ulceration. As soon as the temperature reaches 103° I administer cold as an antipyretic, having the body surface sponged with tepid water, and then with ice water. Do not let the temperature go below 101°. Of those subjected to this treatment, not one in forty has typhoid diarrhoea, and not one in thirty has any delirum. With reference to the complications,

silver nitrate and turpentine resin softened by liquor potassæ are good for arresting hæmorrhage. It should be noted that we are dealing with a fever in which there is a suspension of the normal vital functions. The patient should be fed. The use of milk undiluted produces diarrhoea. The deaths in his hospital service in September and October were four-two from perforation. Out of three deaths last year one was from perforation. From this it will be seen that the treatment is especially protective against accident. Modern physiology teaches that fever is a muscular disease. That the muscular system suffers most severely in the course of the disease. The weakness of the whole muscular system, including the heart and vascular system and bronchial tubes, calls for the early use of cold as an antipyretic. He strongly denounced the coal-tar series, as their action on the muscles and heart is of depressing character, causing tremor. Cold has no such action. If its administration be not carried too far, it certainly invigorates the system, as it produces deeper and stronger respirations and often causes the patient to drop off to sleep. There is also a marked increase of the secretions. He suspends the use of cold in hæmorrhage, so as not to drive the circulation into the viscera. With reference to cardiac stimulants, he, relied on alcohol, but objected to small doses frequently administered. The sounds of the heart are the indications that should guide as to the time and amount of stimulation. When he hears only one sound he orders a stimulant, and continues its administration until he gets the two sounds. Heart failure first shows itself after midnight, and between this time and 6 a. m. a stimulant should be given, and then toward evening again. Not until late in the disease should it be given in the morning. The occasional use of caffeine and strychnine while the pulse is dicrotic is useful and is aided by camphor. Where there is much subsultus, he used sulphuric ether in addition. No treatment can prevent relapses.

Dr. Lesser gave his patients large quantities of water. In 1886 I had a patient with a enperature of 104° to 105°, who refused all kinds of food, and took nothing but water. She lived thus twenty-one days, and the temperature never rose above 102°, after which she recovered. From that time he began to study how much food a patient required. He had had eight cases of typhoid in which no food but water was given for fourteen days, or until the patient desired to

II

have something, and then he began with diluted milk. There is no gastric juice to be found in the stomach in high fever. Even if partly digested food be given, it will not be digested in the stomach, while absorption is greater and of a cruder material. Ptomaines are found which water will not dissolve and absorb. They pass through the intestine. In a disease of this kind, as in scarlet fever, etc., he did not use alcohol as a stimulant, but with caffeine, nitro-glycerin, sparteine, and, if preferred, digitalis, he had been able to overcome the weakness of the heart. There are two indications in typhoid fever for the administration of acids and alkaline waters. When the tongue is red with a brown coating, an acid, well diluted, will always work as a specific. If the temperature has been high before this, it will be reduced. If the tongue be pale and has a dirty gray color, give alkalies. Large quantities of lime water act well in these cases. Patients can live on water without alcohol or other food. Daily washing of the bowels and sponging of the body, together with the other, complete his typhoid therapy.

Dr. Einhorn said that there was deficiency of the hydrochloric acid in the stomach of patients with typhoid fever, but to say the peptic glands are destroyed is going a little too far. There are conditions in which the stomach does not secrete, and yet people afflicted with them can live for an unlimited number of years; here the small intestines does the entire digestive work. In typhoid, the morbid process is in the small intestine; there is, however, a large portion of the small intestine that is not diseased and this does the work. Here give light food, such as diluted milk. An organism can live on its own substance for some time. It is, however, wrong to let the patient starve. In fever, the waste of tissue exceeds the repair. Feed the patient as much as possible. Administer alcohol, not only as a stimulant, but because it furnishes a large amount of material to be oxidized, and in this way saves unnecessary tissue waste.

Dr. A. Russell Bellamy had given over twelve hundred baths in typhoid fever and had reason to study the Brandt method. The present procedure was to cover the patient with only a sheet, and then to lower him into the bath, and rub him until the temperature has been sufficiently reduced. He is then returned to bed, often with difficulty. If he is strong, the muscles are stiffened. At times the patients complain

of a pain and a tired feeling. The close relationship between the visceral and parietal layers of the peritoneum is to be considered. He was inclined to believe hæmorrhage would be avoided if the patient could be more easily lowered into the bath. For these reasons he had devised the following bathing apparatus: It consists of a galvanized iron bath tub, 6 feet 4 inches long, 20 inches wide, and 22 inches deep, provided with a suitable pipe for the escape of the water. The patient is lowered into the bath or raised out of it while lying on a framework which is moved by means of a windlass connected with chains and pullies. The bath tub having been placed alongside of the the bed, the patient's head, then the buttocks, and lastly the feet are put on the frame, and the patient then gently lowered into the tub. By means of this apparatus the patient can be easily bathed by one attendant, instead of requiring six or seven persons as formerly.

Dr. Zeh, in closing the discussion, remarked that his patients had been able to stand undiluted milk, and aided the digestive fluids by giving nitro muriatic acid and pepsin. He had but one case where hæmorrhage occurred, and this patient was benefited by cold applied over the ileo-cæcal region. He made it a rule to use stimulants as soon as the heart showed the slightest weakness.

ASAPROL AND QUININE.-E. Ismail states that asaprol ("West. Druggist") is incompatible with quinine salts. When a solution of basic or neutral quinine sulphate or hydrochlorate is suddenly poured into a solution of asaprol, there forms on the surface of the liquid a resinous body adhering to the walls of the vessel, insoluble in water but soluble in 90-per-cent alcohol. If, on the other hand, the asaprol solution be gradually poured into that of quinine. salt there will be produced a white precipitate, which, after some time, deposits on the bottom of the vessel, instead of floating on the surface, to become pasty and grayish.

MICROBES IN SEWER GAS-Parry Laws states ("Amer. Medico-Surg. Bull.") that the number of micro-organisms in sewer gas is almost always less than in the free air of the locality in which the sewer runs, and that those which are found in the sewer air have a closer relation to the germs of the circumambient air than to those of the sewer. These facts, as

suming them to be true, do not, of course, affect the necessity for excluding sewer gas from dwellings, but they go to show that, whatever the deleterious effect of sewer gas may be due to, it is not due to microbes, and it corroborates the opinion that zymotics which have their origin in sewer contents are more likely to be dissiminated by the direct agency of water and milk than by effluvia escaping into houses. however, there can be no question that such effluvia are greatly productive of diseases of other sorts, cause must be sought for the presence of some chemical ptomaine of non-microbic character.

As,

OBSCURE MENINGITES-Dr. F. C. Bottomley concludes (“Practitioner') that it is difficult to say whether certain meningites be due to tubercle or not. Meningitis may be tuberculous without tubercle being macroscopically evident. Here bacteriological aid is needed. The ætiological value of ear disease is not always easily determined. Evidence of old or recent otitis media is not evidence that the meningitis is secondary to this. Bacteriology is of value only in old ear disease. Certain meningites, after bronchopneumonia and enpyemia, are probably of septic origin. Evidence as to the nephritic origin of meningitis idiopathic cases present the following characteristics: Brain and cord are both frequently attacked, and spinal symptoms are common. These symptoms, if head retraction be not necessarily a spinal symptom, are rare in other meningites which attack brain and cord. In some cases spinal symptoms appear ere brain symptoms. Duration of diseases varies from one to four weeks; the variation depends mainly on the stage of disease at which the membranes are attacked. Recoveries are fairly frequent. Iodides and mercury yield the best results. The cerebral membranes may be either at the base or apex. Cases are most frequent in the cooler parts of the year. This is evidence that these cases may be associated with epidemic meningitis, and that the diplococcus pneumonia may play the chief ætiological part.

PENIS FRACTURE -Dr. Gabzewicz ("Univ. Med. Jour.") reports the case of a thirty-fouryear-old man in whom there was extensive extravasation of blood and gangrene of the penis. The patient made a good recovery with a useful organ. Rupture of the fibrous sheath of the corpora cavernosa had been produced by sudden forcible flexion of the erect pen s.