The patient, who is some 52 or 53 years of age, applied about eighteen months ago for relief from an excruciating headache, for many months so intense at times as to prevent his lying down, pressure on the scalp increasing the pain. Attention was at once attracted to the peculiarities of facial structures presented, and further examination demonstrated the characteristic curvature of the back and enlargement of the hands and feet. Photographs of the patient taken twenty years ago and six years ago, respectively, bear out his statement that his features have materially altered within the last four years, although the latter photograph shows the beginning of the change.

He has had to enlarge his hat-band twice, and his shoes twice within three years. The shoes are a little longer but much broader than formerly. The hands are broadened rather than lengthened; the fingers are exactly "sausageshaped," but thick and clumsy. Distortion of the joints is to be attributed to his occupation, and probably antedates the development of the acromegalic condition. Part of the coarseness of the skin of the hands may likewise be due to occupation. His hands to-day, however, are smaller than when he first came under treatment as shown by our tracings and measurements, and also by his statement that a pair of gloves bought "some years" ago, and too small for him last year, can now be worn.

The enlargement and projection of the superciliary ridges, the lateral projection of the malar bones, the broadening and deepening of the chin, give the face the characteristic lengthened elliptical outline. The great enlargement of the nose; the thickening and projection of the lips; the heavy folds, deep furrows, and somewhat greasy texture of the skin, especially of the forehead; the stiffening and projection of the auricular cartilages complete the picture. The lower jaw does not, however, project beyond the upper jaw. The teeth are bad. The tongue is thickened and deeply fissured. The voice is deep, and has a monotonous quality, the latter only partly attributable to his "boilermaker's deafness." The laryngeal and tracheal cartilages are almost if not completely ossified. thryoid gland cannot be demonstrated.

*Phila. Co. Med. Soc. Trans. Cond.

The

The

forward thrust of head and neck from curvature

of the cervico-dorsal spine throws the clavicles well out from the windpipe, leaving a great hollow just above the sternum. The clavicles are enlarged, the scapulæ are enlarged, the ribs are broadened and apparently in contact, and the costal cartilages seem to be ossified. In consequence, although the narrowing of the chestan apparent lateral compression-and the percussion phenomena show absence of emphysema, it will be observed that his breathing is scarcely at all thoracic. There is an almost inappreciable rise and fall of the clavicles, showing slight vertial motion of the thorax as a whole, and on great inspiratory and expiratory exertion an expansion of one-half to one centimeter can be determined at the nipple line. Breathing is almost exclusively abdominal. This shows, as did my previous case, and some cases of Dr. Dercum's and others, that the disease involves the bones of the thorax, as well as those of the extremities.

The patient is becoming feeble; his muscles are wasting, though as yet electric examination shows only quantitative change. He has vosomotor phenomena-flushing, occasional vertigo, and polyuria. The urine has been deficient in solids, but has not contained sugar or albumen. We have not, indeed, demonstrated anything abnormal in it. This attribute to defective methods of examination. I have no doubt that careful chemical analysis will show in the urine the results of altered metabolism. Since treatment with thyroid-powder was instituted the quantity of urinary water has decreased and the urea-content has risen. Ordinarily thyroid preparation increases both water and solids. Superficially the diminution of polyuria by a diuretic would seem to be an illustration of the so-called "homœopathic law." A moment's reflection, however, shows the action to be simply a correction of disordered metabolism, through which the production of toxins giving rise to polyuria is diminished. Another result of the thyroid-powder has been to completely relieved the distressing headache.

At one time, after a long absence from the clinic, he returned, complaining of violent sciatic pain. It failed to yield to ordinary measures, but disappeared after recourse to thyroid medi

133

cation. Five grains of desiccated sheep's thyroid was given in capsule every morning.

Upon the somnolence, however, no effect has been obtained. The patient can still go to sleep upon the slightest provocation-indeed, without any. He falls asleep while awaiting his turn at the dispensary, and frequently missed appointments through sleeping in his chair over the time set. He says he can keep awake, however, while at work; but as he can no longer do the hard work to which he has been accustomed, he has not for some time had steady employment. Dr. Jackson examined his eyes, and found no lesions of the fundus and no error in the visual field. This goes to confirm the view that hemiopia and other visual errors are secondary phenomena only, due to pituitary enlargement, and that the latter is not necessarily a feature of the disease. I am of opinion that early treatment with thyroid preparations

will prevent overgrowth of the pituitary body; embryological analogy indicating that it is an attempt at compensatory hypertrophy, injurious only because of the altered position.

TYPHOID FEVER.-In treatment, Dr. Elmer Lee (Chicago "Medical Recorder") gives a half tablespoonful of hydrozone to each glass of water. Continued for a few days, it is then laid aside for a few days and glycozon substituted in its place, both as a relief to the patient and for the beneficial effect of the remedy itself. And so on in this way the two remedies are alternated, which is found by me to be the best arrangement for administering these valuable antiseptics. Glycozon is chemically pure, redistilled glycerin, in which ozone or concentrated oxygen has been incorporated, and can be taken with as much freedom and safety as pure glycerin. The glycozon may be taken in doses of half a tablespoonful to a glass of water as often as water is taken during the day. When it is desired to allay nervousness and induce sleep at night, codeine sulphate is used, in doses of from one-half to one grain, by the mouth, or onequarter to one-half grain by the hypodermic method. This tranquilizes the nervous system and induces sleep. The typhoid fever patient receives as food whatever is simple, at regular intervals of four hours. Milk, simple, natural milk, is nourishment of the highest importance. One egg every day, or every other day, is alternated with a small teacup of fresh pressed juice from broiled steak or mutton. The egg is

pleasant to take and more nutritious when whipped till it is light and then stirred with a small glass of milk.

MIGRAINE IN INFANCY.-Infancy escapes few of the neuroses of mature life. The diagnosis is obviously embarrassed by the difficulties attendant upon the elicitation of symptoms. Thus, it has been conclusively demonstrated that infants and young children may be unequivocally hysterical. There is reason to believe that they may be similarly affected with migraine. Evidence in support of the latter proposition is furnished in a report by Betz (“St. Louis Med. and Surg. Jour.") of a case of a female, thirteen months old, who at a time when influenza was prevalent was seized with an attack of febrile gastro-intestinal catarrh, attended with diarrhoea. During the course of this illness the infant was seized with twitching, affecting principally the hands and arms, occurring intermit

tently and also during sleep. It further indicated by gesture pain in the head. Consciousness was perverted, but not lost. It was observed that the child manifested a tendency to grasp the left side of its head and to lie upon its left side; and upon examination the left side of the head was found to be somewhat smaller in size than the right, while further investigation disclosed the fact that an elder sister and the mother botn presented a similar asymmetry and suffered from attacks of migraine. The interesting features are the age, sex, heredity, and face asymmetry. In a diagnostic connection it is pointed out that on palpation the temperature may be found higher on the affected side than upon the opposite side, and that during the attack of pain the upper lid upon the affected side diplays a tendency to droop. Therapeutically general rather than special measures are indicated. Opium may be used internally and topically with caution; ice water compresses; topical applications of menthol, cocaine or ether may aid in the relief of pain.

HYDROGEN PEROXIDE A HÆMOSTATIC.Dr. Brewer calls attention to the hæmostatic property of hydrogen peroxide (Marchand). He has used it to arrest hæmorrhage after operations upon nose and throat, and found it promptly effectual where other methods, including styptics and plugging, had failed. ordinary 15-volume solution is to be applied either on a cotton swab or sprayed directly upon the bleeding surface.

The

undoubtedly not in normal condition, as revealed by auscultation; but the cardiac muscle can, nevertheless, functionate freely and regularly. The stage of tolerance gives way to multiple circulatory disorders, variable functional disturbances, and secondary alterations. In the acute period when careful examination reveals the first indications of valvular myocardiac or pericardiac inflammation-local or general intervention becomes necessary. Local treatment may consist in applying wet cups, or, if these be not at hand, leeches over the precordial region. The former are considered preferable, since their application is more rapid, exposes the patient less to "cold," and allows an exact limitation of the quantity of abstracted blood. After this local blood-letting, a sufficiently large blister, three and one-fifth to four inches in diameter, should be applied, and covered with oiled silk to prevent the absorption of the vesicating principle of cantharides, and eventual bladder trouble. At least one day should intervene between these applications. When the disease begins to recede, the vesicants may be replaced by iodine applications; the tinctures, iodized cotton, or iodine ointment. In the initial stage, internal treatment may consist in administering calomel in 7% grain doses as a purgative, to be followed by special medication, as the case may indicate. For instance, in rheumatic endocarditis, Potain recommends sodium salicylate; if the endocarditis originate from some gouty affection, he prefers colchicum tincture, in fractional doses, increased to the limit of tolerance; in other cases, especially in typhoid fever or the grippe, he advises quinine sulphate. The acute period of endocarditis is not habitually accompanied with any marked disturbance of the cardiac rhythm. The irregularity and the sometimes excessive frequency of the heart beats call for the use of cardiacs; as digitalis, particularly in arhythmia and tachycardia,

caffeine in weak heart and acute dilatation of the organ, and strophanthus in marked precordial oppression. The patient must remain in bed. Feeble persons should be supported by vigorous milk diet, provided there be no absolute intolerance; and the milk (in pint doses daily) does not, it is stated, give rise to gastric disturbances, as a rule. Mild soporifics may be prescribed. The slightest cause of mental excitement should be avoided. As regards treatment in the stage of tolerance, Potain proposes: To maintain tolerance by preserving the patient's general health

and removing all possible cause of disturbance, to confine the cardiac myopathy within its limits as well as possible, having the patient follow an occupation beneficial to his health. The causes of disturbances to be avoided are: Diseases capable of bringing on a new attack of endocarditis or myocarditis; energetic muscular exertion excessively stimulating circulation; imprudence of diet; stimulant beverages; mental agitation; and sexual excitation. When the patient has reached the convalescent stage, his functions are more or less altered and weakened. Corpulent persons are advised to use Swedish movements with due regard for the patient's power of endurance as to muscular activity; walking, etc.

Dr.

UTERUS FOREIGN BODY.-Dr. L. A. Grizzard, Abilene, Texas, reports ("Med. Brief") the case of a single woman who passed a new lead pencil, full length, into the uterus. Grizzard could not liberate it. In six or eight weeks he was sent for and found a tender, fluctuating, inguinal swelling on one side. He opened it and found the lead pencil, which, entering at the os uteri, had penetrated the uterine wall, broad ligament, and approached just beneath the surface of the skin, to be liberated by the aid of the scalpel.

HERMAPHRODITISM.-Dr. G. Bergenzelli reports ("West Med. Rep.") the case of a 38year-old Italian in whom the hairs in the pubic region extend to the umbilicus, the whiskers are thick, the pelvis of male conformation, and the external genitals exhibited a vulva with the labia majora interposed in the superior extremity by

the base of a well formed penis 6 centim. long, increasing 3 centim. during erection. The glans is well formed, has a slit in its inferior part, ending in a cul-de-sac; the prepuce adheres to the

nymphæ, a median raphe in the lower surface of the penis leads to the meatus and presents in its extremity Pozzi's frænum. The vagina is narrow, and digital examination reveals the presence of the uterine neck. Menstruation has been

regular since its appearance at the age of eighteen years. This individual has had sexua] relations both with male and female, has aborted twice, but has never impregnated any woman. The case is one of gynandrism with female predominance.

THE MEDICAL STANDARD, knowing the disgraceful management of the Chicago Health Department during 1891-2 with its resultant demoralization, has refrained from criticizing the present health commissioner for not performing impossibilities. In 1891-2 the health commisioner made Chicago the laughing-stock of Europe by stating that its large typhoid fever and diphtheria rate was due to diagnostic errors of the physicians who reported too many cases. The character of the medical politicians employed may be judged from the prophylatic recommended by one of them against diphtheria. The way to prevent diphtheria was to place sulphur in a tin saucer, and put a lamp chimney thereon, and to hold the child's nose thereon for two hours. The statement of the "sanitarian" that the child would not thereafter take diphtheria was probably correct. It would be proof in all likelihood against all diseases for the future. This distinguished "sanitarian" set at defiance the diagnosis of physicians, tore down diphtheria placards which interfered with saloon traffic, and consigned the neighborhood thereby to infection. Physicians were discouraged from reporting contagious diseases by public sneers cast on their diagnosis from ignorant medical politicians. The proprietors of saloons, sweater's shops, tenement houses, etc., were encouraged to violate the placard law by the knowledge that the "sanitarian" aforesaid would agree with their diagnosis. To such a state of things, demoralizing to the worst possible degree, the present administration succeeded at a trying time. Its medical critics are the "sanitarian" aforesaid, wisely removed by the present commissioner for good and sufficient reasons, a medical tool of the county boodle gang of 1886-7, and a go-as-you-please gynæcologist, who was a tool of the 1889 county "stone-jobbers" who fed the insane on "green meat."

Both of these last were blatant eulogists of county brutalities in the way of rotten food and poor raiment for the sick and insane. Their attacks suggest that Dr. Reynolds has fought some contract which has "boodle" in it for their political patrons, especially when it is remembered that the sensation-mongers supporting them were organs of boodle contractors and methods in county institutions. The Health

Department was so demoralized by the previous administration, whose ignorance was the scoff of medical Europe, that it is hardly surprising that a year has proven insufficient to correct its defects.

THE bubonic plague, the terror of Europe even to the close of the seventeenth century, has again made its appearance in China, where it is more or less endemic as it is in Asia Minor. The "British Medical Journal," while admitting the vividness of the picture drawn by Defoe, points out that:

While much in his "Plague of London," his description of the phenomena of the disease is fairly accurate. The present title is derived from the swelling in the groin. In the earlier plague, a similar swelling in the axilla was a frequent symptom. The disease is a rapid, malignant, contagious fever, accompanied by buboes, carbuncles, and livid spots. At least two-thirds of its victims die. Its symptoms are violent headache, accompanied with violent tremors alternating with intense heat. The eyes become red and assume a ferocious aspect, resembling those of victims of hydrophobia. The pain extends from the head to the spine, joints, and limbs. Then follow vertigo and delirium. The tongue is dry and yellowish. Respiration is difficult, nausea occurs, but rarely vomiting. The disease runs its course in from three to seven days. The patient often dies in a few hours. The first known appearance of the plague in Europe occurred 430 B. C., when it depopulated Athens, reaching there from Egypt by way of Libya. It was brought into Europe by the returning crusaders, and has frequently appeared since, always coming from some part of the Turkish dominions. It appears in lower Egypt, Syria, and Turkey about every seven or ten years. It has often made its appearance in London, the most frightful visitation being in A. D. 430, when there were scarcely enough living left to bury the dead in all England. In A. D. 716 Constantinople lost 200,000. In 1348 Germany lost 90,000. It has scourged various parts of Europe from time to time since, carrying off hundreds of thousands at each visitation. In Egypt 800,000 died in 1792. The latest visitation of which we have an account at hand was in 1813, when it was exceedingly fatal in Egypt and in Malta.

THE forensic error involved in taking trichomonas vaginalis for spermatozoa has been recently illustrated by Dr. Sangnee ("Times-Register"), who stated that in a Philadelphia bacteriological laboratory a student was asked: "What parasite frequently infests the vagina?" In all seriousness the rising young bacteriologist promptly and confidently answered, "spermatozoa." The questioner had in mind the tricho