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LITERARY DOCTORS AND DOCTORS IN LITERATURE.—The medical profession has seldom been appreciatively portrayed in fiction. In not a few notable instances it has been unjustly depreciated, either directly or by inference. Recent years, however, have seen Dr. William Maclure appear as the noble hero of “Beside the Bonny Brier Bush. In his homely dialect, James Whitcomb Riley has described the faithful country-doctor of the West in its early days.

Dr. Weir Mitchell has given us, in his "Hugh Wynne," an admirable picture of Revolutionary times and life at that period in Philadelphia. Dr. Mitchell's work is one of the best novels published in America and dealing with an American subject.

Both these works should be in every physician's library.-The Medical Bulletin.

HYPERIDROSIS. -For sweating of the axillæ the following formulæ will be found useful:

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R Tannin, :

gr. xx; Oil of pumilio pine,

3 ij; Absolute alcohol, q. s. ad

3 ss. Either of these may be used freely night and morning, or as often as may be found necessary.-Dr. William Murrell, of London, in the Medical Brief.

FOR FACIAL ERYSIPELAS (Medical News) :
B Ac. carbolici,

Tr. iodi, kā
Alcohol,
01. terebinth,

Glycerini, ..
M. Sig: Paint over affected parts.

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gi;

3 ij;

3 iij.

A PHYSICIAN VICTORIOUS IN A MALPRACTICE Suit.-We congratulate Dr. C. D. Palmer, of Cincinnati, on the fact that, as we learn from the Cincinnati Lancet-Clinic, the malpractice suit brought against him in the name of a Mrs. Eiselein has been decided in his favor. The suit was brought about eight years ago, and has been stubbornly contested.

A Powder FOR VAGINAL DRESSINGS.—The Journal de medecine de Paris for February 6th attributed the following formula to Lucas-Championniere: Take Iodoform, powdered benzoin, powdered cinchona, magnesium carbonate saturated with oil of eucalyptus, equal parts. Mix.—New York Medical Journal.

Special Notices.

THE MEDICAL TREATMENT OF GOITRE.-In view of the inefficiency of medical agents in the treatment of simple goitre this affection came gradually to be recognized as a surgical disease. Yet while nunierous cases have been cured or greatly improved by surgical measures, the various operations employed are attended with more or less risk of life even in the hands of expert operators, and are sometimes followed by serious sequelæ, as operative niyxedema. The demonstration of the fact that many of these cases can be ameliorated or even cured by thyroid feeding has again given an impetus to the medical treatment of goitre. As the thyroid preparations in use, however, vary greatly in their content of active ingredients, the results derived from their administration have lacked uniformity. Now that the active principle of the thyroid gland has been isolated by Prof. Baumann, and presented to the profession in the form of a trituration with sugar of milk under the name of iodothyrine, it will be possible to obtain the full advantages of the thyroid treatment.

This statement is borne out by the favorable results already secured from the use of iodothyrine in cases of goitre, and this remedy appears to be a valuable addition to the medical resources of the physician in the management of this disease, especially in its earlier stages.

CONFIDENCE WELL PLACED.-John Carle & Sons, New York City. Gentlemen : You can be assured that I will prescribe the IMPERIAL GRANUM whenever there is an indication for a prepared food, because I had sufficient confidence in it to give it to my own child, and it agreed with him perfectly, and he has increased in size and weight to an astonishing degree.

- M. D. Physicians can obtain samples of this celebrated prepared food free, charges prepaid, on application.

December 6, 1897.

SPERMATORRHEA.-Having a case of spermatorrhea of several years' standing, which came under my care about nine months ago, I prescribed the usual remedies, in this case, viz., bromide potash, ergot, ferrum, digitalis, belladonna, and cimicifuga, with very unsatisfactory results. Seeing your preparation, Celerina, reconimended for this affection, I procured some and administered it in this case with such marked results after the use of the first bottle that I immediately ordered two more bottles, which have entirely cured him of this affliction. I have two other patients now under treatment with Celerina which are progressing very favorably. After a practice of twenty-nine years I have no hesitancy in saying that it is the most effectual remedy that I have ever prescribed in the above disease. Quarryville, Pa.

H. E. RAUB, M. D.

The kidneys are purely excretory organs. Through their action the blood is kept pure. If their function is suspended or imperfect, disease follows and calculi form; cystitis and inflammation of the entire urinary apparatus is the result. This includes the prostate. To restore health the kidneys must be brought into faithful service, When this is done, the whole train of morbid symptoms gives way. Maizo-Lithium will do this in the most effective manner.

We call the attention of our readers to the advertisement of the Robinson-Pettet Co., Louisville, Ky., which will be found on another page of this issue. This house was established fifty years ago, and enjoys a widespread reputation as manufacturers of high character. We do not hesitate to indorse their preparations as being all they claim for them.

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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 plaivest 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.

Original Articles.

PROLAPSUS RECTI AND INVAGINATION.*

BY JOHN MASON WILLIAMS, M. D.

I am well aware of the fact that it is a rather difficult task for a specialist to write upon a topic that is of decided interest to the general practitioner. However, I have ventured this subject because of its frequency in all classes and ages, the aged and the very young being more especially prone to the condition.

Prolapse of the rectum and invagination is divided into four distinct degrees or varieties, as follows:

1. Prolapse of the inucous membrane only.

2. Prolapse of all the coats of the wall of the rectum, beginning at the muco-cutaneous junction and including, when the prolapse is of sufficient extent, the peritoneal cul-de-sac.

3. Prolapse of all the wall of the rectum that has as its starting point a point more or less removed from the anal orifice and yet extrudes from such orifice.

4. Prolapse of the upper half into the lower half or of the colon or sigmoid into the rectal ampulla without protruding from the anus.

The first degree is simply an exaggeration of a physiological action that takes place with each and every defecation, a mere everting of the mucous membrane of the lower part of the rectum, rendered possible by the laxity of the submucous connective tissue. It is seen in most all old cases of hemorrhoids, ulceration, or fissure, or any condition *Read before the Louisville Medico-chirurgical Society, February 25, 1898. For discussion see p. 271.

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where there is straining at stool. It is very perfectly demonstrated upon the horse with defecation. This form of prolapse is most common of all and is seen most frequently in children, and in adult life inore frequently in women than in men, due to chronic constipation which is frequently the result of a false modesty. The causes are numerous, and most diseased conditions of the rectuin or anus are followed by or accompanied with prolapsus. Among the causes we will enumerate hemorrhoids, polypi, new growths, ulceration or incision, traumatism, constipation, spinal paralysis, fissures, dysentery, worms, stricture of urethra, phimosis, cystitis, stone in bladder, pregnancy, parturition, fecal impactions, diseased liver, and many other conditions. This form is usually gradual and rarely if ever sudden in its appearing. It may involve the whole of the circumference or only a part; it appears as a scarlet or livid mass as to contractility of the sphincter. It is unmistakable and easy of diagnosis. The cause should be ascertained and treated independently, and following this some simple astringent application and the application of the adhesive plaster strips after the inethod recently revived by Powell, of New York, which consists in bringing the buttocks in close apposition by adhesive strips, and confining bowels for three or more days, afterward using cold water to the parts for a few days. This will usually result in a cure; and, if failure follows its use, a second or third attempt should be employed before advising a more radical operation. The prolapse is generally reduced automatically after stools, and can at least be reduced by patient, or parent if it be a child, with little or no difficulty.

Should the prolapse persist, the best operation for radical cure is the Van Buren operation of linear cauterization, done by actual or Paquelin cautery, by making three, four, or five longitudinal stripes with the iron at a dull red or cherry heat, parallel with one another. In this manner all the coats of the rectum are bound firmly together and will remain permanently in place. The operation of excision of mucous membrane is hardly justifiable in this condition with its train of possible complications, such as failure of union by first intention with consequent ulceration and perhaps stricture. Prolapse of the second degree is usually the result of a first degree prolapse, but it may come on suddenly as the result of violent straining at stool, a fall or crushing accident. It differs from the first degree prolapse only in one particular, that being its involving all the coats of the wall of the rectum. It is distinguished from the first degree by the folds of the mucous membrane,

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which now appear circular and surround the prolapsed organ in crescentic folds, whereas in the first degree the folds run up and down and radiate toward the center of the aperture. It is always much greater in size, due to the amount of tissue involved.

A prolapse of the second degree, if sufficient in extent, will usually contain a fold of peritoneum or a continuation of the cul-de-sac. All cases of prolapse of more than two and one half inches should be regarded as accompanied by an archocele or rectal hernia. It is almost impossible to tell by physical examination whether a prolapse contains peritoneum unless there exists a rectal hernia which may be diagnosed by the following physical signs: Gurgling upon palpation and resonance upon percussion, and its entire disappearance when patient is placed in knee-chest position.

The causes are practically the same as in the first degree. The symptoms are aggravated, increased pain, discomfort caused by extruded mass, more or less hemorrhage, often excoriation and ulceration, and slight incontinence of feces, due to weakened condition of sphincter muscle, tenesmus, etc. The treatment differs whenever you may have peritoneum to deal with. The first thing to do in case the prolapse is strangulated is to attempt reduction at once, as gangrene may rapidly

Reduction is usually accomplished by thorough lubrication of the parts with vaseline or oil, and gentle taxis; reversing the steps of the procedure an anesthetic may be necessary. Operation is not advisable under these circumstances, and after reduction the patient should be placed in recumbent posture and made to remain there for several days, the bowels being moved in this position with aid of bed-pan. Cold water may be injected into the rectum twice daily and cold applications kept on external parts. If much pain, an ointment of belladonna and opium, equal parts, will usually suffice. Should the prolapse recur, which is highly probable, immediate operation should be done. The linear cauterization is again advised as being quicker, freer from pain, and safer as to the peritoneum. Great care should be taken when applying the iron not to go deeper than the muscular coat. As a guard against this the cautery point should be well curved or bent at right angles near its point. This operation followed by rest in bed for two weeks will usually cure.

The operation of excision is very dangerous; if the peritoneum be involved an infection is difficult to prevent. The operation of ligaturing the same as for piles or the application of clamp and cautery after the

ensue.

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