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of some form of phosphorus, either liquor acid phosphoric comp., Horsford's acid phosphates, Parrish's chemical food, the syrup of hypophosphates, or hypophosphites. The phosphates of iron, quinia and strychnia are valuable when the appetite fails. In this case it is well to apply some preparation of iodine externally behind the angle of the jaw; either apply compound iodine ointment or an ointment of the iodide of ammonium. The muriate of ammonia has been recommended in all these cases. In interstitial hypertrophy also the bromides of ammonium and potassium may be given internally.

As regards the local treatment of the tonsils, much difference of opinion seems to exist. In older children and in adults it has been the custom where this hyperthrophy is great to ablate the tonsil, some advise almost an entire ablation, others simply slicing off either upper surfaces. At the present day the actual cautery, especially the galvano-cautery, has been used for this purpose, and in my own experience where the condition is one of long standing, it seems to be followed by good results.

Meigs and Pepper recommend the injection of iodine in dilute solution, three to five drops into the gland very gently about once a week, according to the effect produced in the children old enough for this treatment. The application of nitrate of silver, especially the solid stick to the surface, laid lightly, has also been of advantage, or a solution of nitrate of silver, ten grains to the ounce; Lugol's solution diluted with two to four parts of water, applied locally, is also recommended by them, also the application of Lugol's solution with glycerine every other day.

CLINICAL LECTURES.

ENLARGEMENT OF THE HEART. TUBERCULAR TROUBLE.

BY JOSEPH P. ROSS, M. D., CHICAGO, ILLINOIS,

Professor of Clinical Medicine and Diseases of the Chest, in the Rush Medical College,
Chicago.
REPORTED FOR THE PHYSICIAN AND SURGEON BY SPECIAL STENOGRAPHER.

GENTLEMEN: Our first patient, Mr. P., twenty-three years of age, was born in Pennsylvania, and at present is a resident of Chicago. Antecedent to the present illness, his general health always good; sisters and brothers were all healthy, but mother died of pneumonia at the age of thirty-eight. His habits have

not been good; hygienic surroundings excellent; food and clothing good. He ran across a viaduct and very soon after was seized with spitting of blood, dark at first, afterwards red. He then grew weaker and weaker, until he could not work, and has not worked since. He had a cough, which became less, after taking some cough medicine for a little while. You will observe he is somewhat emaciated; his skin is normal in color; pulse a little quick, full, and somewhat soft; temperature, 99; respiratory movements, 16 to 17; tongue normal in size and color, not coated. He has no pain at present, but a little at times in the region of the heart. The apex is found to beat in the seventh intercostal space; no murmurs with the first sound; first and second sounds at the base normal; impulse is increased below; dullness is more marked over the pericardium than usual. There is greater dilatation of the right than the left lung; marked dullness is heard over the left apex. The heart is evidently enlarged. There are no valvular lesions, because the sounds are normal; but we get over the left lung some signs of a deposit with bronchial rales. The physical signs are those of enlarged heart, with a little deposit of some kind in the left lung, giving us bronchitis.

With reference to bronchitis, I desire to say, you almost always find in cases of lung trouble bronchial rales in the affected lung. If you have a tubercular deposit you will get it in the region where the deposit is. Catarrhal bronchitis, as you doubtless know, involves both lungs alike. It is a bilateral disease; it is not local. If it is local, look out, there must be some local cause for its development. We have not only bronchial rales on that side (the left), but a loss of motion; a little roughening of the vesicular murmur. With this brief and meagre history, I do not see how we can make a diagnosis other than that of enlarged heart. It may be a matter of injustice to the patient, but I must say this disease was undoubtedly brought about by his bad habits. We do not get a murmur that indicates valvular lesion of any kind.

We are informed also, that along with the patient's cough medicine there was added five drops of digitalis to keep the heart stable. Now, we know that digitalis is a good cardiac stimulant, and where we have dilatation to such an extent that the organ is considerably weakened in consequence, I would not hesitate to give it for the purpose of strengthening the heart, but in this case I am disposed to put the patient (knowing he has considerable bronchitis) on tonics, such as quinine, iron

and strychnine, before meals, and give him a cough medicine of some kind after meals and at bedtime.

Michael D., aged forty-five years, Irishman, laborer, married; health generally been good; no hereditary predisposition; temperate in habits; hygienic surroundings have been fair. June 1, got wet feet while working; had a chill June 9, and has had chills frequently since, which have occurred recently, almost daily. About six weeks ago noticed sputum was streaked with blood; lost from twelve to fourteen pounds of flesh; has chills in the fore part of the night, followed by sweating; has taken three to five grain pills of quinine.

You notice the patient is emaciated; his face has a dull expression; skin normal in color; pulse normal, with temperature, 100°. Respirations, 22 to 23; tongue clean, but slightly coated; pain in the right side.

Tubercular trouble generally selects the apex of the lungs. You find it begins there in probably ninety-nine out of every one hundred cases. We have impairment of the respiratory murmur; the patient is considerably emaciated; he has cough. We have a large number of deaths every year in this city from tubercular troubles. I do not suppose we have any more than the northern cities. We all know we have bad weather in Chicago from January to June; that is when these cases are affected badly.

We have a fatality every year of three to four millions going that way. About thirty years ago I began chest treatment, and to hold clinics. We commenced then with cod-liver oil, and although I have kept pace with the literature on the treatement of these affections, I do not believe we have got anything much better than what we commenced with. I have apparatuses and all the equipments adapted for the new treatment of pulmonary troubles (of gaseous injections per rectum, etc.), and I must confess I have not very much faith in it; and hence, I fail to see the utility of giving this man a gaseous injection. I would first build up his digestive organs; try and get him to eat good food. We will give him for his night sweats, sixtieth to a hundredth grain of atropia at bedtime; we may also begin with three grains of quinine, lemon juice, and three teaspoonfuls of water, enough as an appetizer, at bedtime to break up his chills, and pyrogallic acid and quinine during the day.

After continuing this for a time, we might then give him. a nourishing tonic, such as cod-liver oil.

ORIGINAL TRANSLATIONS.

FRENCH LITERATURE.

TRANSLATED BY C. J. MINER, ANN ARBOR, MICHIGAN.

TUBERCULOSIS OF THE JOINTS.

Dr. Kölischer has just described a new method of treatment of localized tuberculosis. The new theory is based on the following considerations. Firstly, he tried to produce a calcification of the tuberculous seats, analagous to the spontaneous calcification that takes place in the lungs, by the injection into the fungus masses of a sufficient quantity of the salts of lime. Secondly, he sought to establish by these injections a process of acute inflammatory irritation in the tuberculous granulations and to produce in this manner a cicatrization of the tuberculous nodules.

In the experiments he tried in the clinic of Professor Albert he used parenchymatous injections of solutions of the phosphate of lime, and obtained very favorable results in about six weeks.

One of the cases that he treated by this method, and that he showed in one of the recent meetings of the Royal Imperial Medical Society, was that of a boy aged four years affected with fungus granulations (tuberculous) of the knee-joint, with very grave symptoms such as ankylosis, lateral mobility, swelling and pain. A cessation of the morbid processes was obtained after a treatment of five weeks.

Among the other cases he had treated by this method should be mentioned two cases of fungus granulations of the elbowjoint, in which the patients suffered ankylosis, followed by swelling and great pain; these symptoms also accompanied by fever. After a treatment of six weeks the joints became normal and complete mobility was obtained.

Among these cases Dr. Kölischer showed to the Society a case of calcified caries of the hand and the cure of a tibio-tarsal fungosity, in which was also observed a circumscribed necrosis of the bone.

In the first experiments Dr. Kölischer used a solution of the chlorate of lime for the parenchymatous injections, but afterwards, following the advice of Dr. Freund, he used a solution of the phosphate of lime with a surplus of phosphoric acid.

The injections are accompanied by a serious reaction, especially when the chlorate of lime was used. The fungus masses

opened and healed in a short time, and when there was a bit of necrosed bone in the fungosity it opened quickly and the necrosed bone was expelled with a rapidity that could only be attributed to the success of the treatment in question.

The injections themselves are very painful, and recourse may be had to the use of cocaine with great advantage. After the injection is finished, also, great pain is observed, which lasts for some hours, and which is only relieved by the subcutaneous injection of a sufficient quantity of morphine. Immediately after the injection an antiseptic dressing should be applied, which should remain on the part operated upon all the time of the reaction.

The fever temperature which accompanies the reaction is ordinarily very high, and lasts from twelve to twenty-four hours.

When the reaction, which lasts for five or six days, has diminished, a starch dressing should be applied to the joint, which should be changed as often as it becomes relaxed; and after an interval of three to six weeks, when the state of solidification and freedom from pain is completely established, recourse may be had to massage and passive movements to reestablish the mobility of the joint.

As to the composition of the solutions of the phosphate of lime used for the injections, Dr. Freund, who elaborated the chemical part of the discovery in question, gives the following formulas:

(1) Acid solution of the phosphate of lime, approximately six and five-tenths per cent., containing one in one thousand of free phosphoric acid (sterilized for injection).

R. Neutral phosphate of lime...........

Distilled water.........

5.0.

50.0.

Then add slowly phosphoric acid to perfect solution; filter and add dilute phosphoric acid six-tenths, and distilled water to one hundred for injections.

(2) Acid solution of the phosphate of lime, approximately six and five-tenths per cent. containing one in one hundred (or two in one hundred when the ulcerous process is very indolent) of free phosphoric acid, for the saturation of the gauze.

R. Neutral phosphate of lime...........

Distilled water...........

50.0. 500.0.

Then add slowly phosphoric acid to perfect solution; filter and add dilute phosphoric acid sixty (or one hundred and twenty), distilled water to one thousand, for the preparation of the guaze.

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