INSANITY AFTER KEELEY CURE. effect would necessarily be bad upon the attendance at the Keeley institute of having the cases of failure staring the new cases in the face. Dr. Keeley claims 95 per cent of cures and the figures of the bichloride of gold clubs are even higher, but they both neglect to state, so far as I have observed, what constitutes a cure. Does a cure mean one or five years of abstinence? And do the figures given embrace all the cases treated, or only those about whom information is forthcoming? In the first place drunkenness is not like rheumatism, paralysis, consumption and bodily diseases, whose presence or absence can be demonstrated. The cure of drunkenness is a more difficult matter to ascertain. No one can follow up all Keeley's patients for months and years to see how they turn out. Patients may be still drinking in the outside world and still deny it or deceive others. There are many whose paroxysms of drinking are months, or even years, apart, and there must be hundreds who drop out of sight, especially if they relapse. Some relapses are admitted, even by Dr. Keeley, and yet he announces that his remedy is "infallible," printing this word upon the label of his bottle, and of course if his claims are correct the percentage of cures would be 100 per cent. The department of publicity and promotion of the Keeley enterprise is one of the most important factors in its success. A large proportion of the advertising is spontaneous; it is secured gratis. If it be true that there is something essentially new in Keeley's treatment, a motive for concealing it becomes at once apparent on the supposition that he wishes to derive personal advantage from his invention. But if he wishes to derive personal advantage, and there is nothing new or important in his system, the motive for concealment is equally apparent, and the personal interest is the same in either case. The imposition of outsiders is greater than it would be if his processes were not secret, while if the facts were known skillful and scientific men could universally make use of them for the benefit of all. Keeley's efforts to keep his process secret are inexcusable from the standpoint of science and humanity and medicalethics. Koch ultimately placed his discovery in the hands of the world, and it was tried and found valueless. It remains to be seen how true Keeley's claims may be, but if Keeley should prove as seems likely to be a Barnum of medicine, rather than a Jenner or a Lister, I should owe an apology to 5 Koch for coupling his still great reputation with that of an adventurer who knows how to turn human credulity to personal account. Dr. Keeley, in a lecture delivered to his patients at Dwight, in March 1892, states that he is not called a Christian, but does believe in special providences, and believes that his discovery is a special providence. This is the first instance of a special providence offering its services for cash. Verily he has his reward at the rate of $10 per bottle and $25 per week. TONGUE CANCER.-Dr. N. P. Dandridge concludes, in a paper read before the American Surgical Association, that: Sufficient experience has been accumulated to show that the removal of cancer of the tongue prolongs life and adds to the comfort of the patient and further affords a reasonable hope of permanent cure. All operations should be preceded by an effort to secure thorough disinfection of the mouth and teeth. In the treatment of continued ulcers and sores on the tongue, caustics are to be avoided and all sources of irritation removed. Persistent sores on the tongue should be freely removed by knife or scissors if they resist treatment. When the disease is confined to the tongue, Whitehead's operation should be employed for its removal. In this operation, the advantage of preliminary ligation of the lingual artery is not definitely settled, but the weight of authority is against its necessity. The advantage of leaving one half the tongue in unilateral disease must be considered undetermined, but the weight of positive experience is in its favor. In splitting the tongue into lateral halves. Baker's method of tearing through the raphe should always be employed. A preliminary tracheotomy adds an unnecessary element of danger in the removal of the tongue in ordinary cases. When the floor of the mouth has become involved or the glands are enlarged, Kocher's operation should be employed, omitting the spray and preliminary tracheotomy. Removal of the glands by a separate incision after the removal of the tongue must be considered insufficient. Volkmann's method still rests on individual experience. Its just value can not be determined until it has been subjected to trial by a number of surgeons. Thorough and complete removal should be the aim of all operations, whether for limited or extensive disease. By whatever method the tongue is removed, the patient should be up and out of bed at the earliest possible moment, and should be generously fed. FATAL SUPRA-PUBIC BLADDER ASPIRATION.* BY FRANK DYER SANGER, M. D., BALTIMORE, MD. The case I am about to relate was that of a 75-year-old white man, large, rather fleshy, full habit. Had had trouble passing his urine for some time, but never retention. For three days had suffered much pain in the region of the bladder, and could only pass a small quantity of urine at a time. Examination showed the bladder to be moderately distended, its summit about two inches below the umbilicus. A hot bath gave no relief. A number of strictures were found in the urethra, nevertheless a long curve catheter was passed as far as the prostatic urethra; nothing could be passed further. Seven hours after the patient was first seen aspiration was determined upon, as I felt sure the bladder would suffer if not soon relieved. A double inguinal hernia and a rather thick accumulation of fat over the pubes decided me to insert the needle well up. Having used thorough antiseptic precautions, I felt that I could pass the needle through the peritoneum with safety. About one quart of urine was removed from the bladder. A drop of blood followed the removal of the needle, the point of puncture was covered with a strip of adhesive plaster and the patient went to sleep. Next day his bowels moved freely, and he passed considerable urine, a part of which escaped into the bed and could not be measured. The morning of the second day after the operation he complained of pain in the lower part of the abdomen and tenderness. Bladder could not be felt; pulse somewhat accelerated; temperature normal. Toward evening abdomen became tympanitic, pulse more rapid, temperature 98, expression anxious, urine passed in small quantities. Bladder could not be made out. Opium given to relieve pain and heat applied to abdomen. Patient died next morning, sixty-two hours after the aspiration. The needle had entered the abdominal wall two inches above the upper border of the symphysis pubis. A line of light extravasation marked the track of the needle through the wall and parietal peri toneum fold; further than this its track could not be positively determined as the pelvic cavity was filled with blood. Dense adhesions bound the bladder in all directions, which required considerable force to be broken up. There was considerable redness of the parietal and visceral peritoneum in the vicinity of the bladder. No *Maryland Clin, Soc. Trans. Cond. pus or urine apparently. In freeing the adhesions about the bladder that organ was ruptured, and about half a pint of turbid urine escaped. I removed the bladder and urethra en masse, but was prevented from further examination by friends who came to claim the body. There have been a number of deaths reported from supra-pubic puncture for the relief of a distended bladder. Deneffe and Van Wetter in 1877 collected 152 cases of supra-pubic puncture with six deaths; eighty-seven cases of rectal puncture with eleven deaths. I have not been able to find another case of accident from aspiration in the literature, though my search has not been by any means exhaustive. Deneffe and Van Wetter report fifty-seven cases of aspiration with no accident, showing the improvement upon puncture. The case here reported proves at least that aspiration is not free from danger, and suggests greater circumspectness in its practice. Dr. W. P. Chunn said that, in these cases of distended bladder, by sticking close to the symphysis the bladder can be reached without striking the peritoneum. In this case under consideration some urine trickied into the peritoneum and caused peritonitis. Dr. J. W. Chambers looked with apprehension upon every distended bladder in old men who had enlarged prostate. The amount of hæmorrhage resulting in Dr. Sanger's case merited attention. The enlarged prostate interfered with the circulation, and the veins on the anterior vesical surface thereby became varicose. One was probably punctured. The peritoneum was probably infected through the needle becoming infected in the bladder. PHOSPHORUS IN FEVERS.-Dr. J. W. Duncan, of Atlanta, states, in a paper read before the Georgia Medical Society, that phosphorus is a very excellent nerve tonic and stimulant, acting on the circulation through the nervous system, causing the pulse to be fuller and more frequent, distending the capillaries until free perspiration follows, and from its primary action increasing the heat of the surface of the body slightly. Its secondary effect lowers temperature. It accelerates cell growth in the body. It acts as a diuretic. The urates and urea are greatly increased in the urine; but it should not be regarded as a specific in fever. CHILDREN'S DISEASES. ང་ 7 SUMMER DISEASES OF CHILDREN.* BY W. S. CHRISTOPHER, M. D., CHICAGO. FELLOW OF THE CHICAGO ACADEMY OF MEDICINE. PROFESSOR OF CHILDREN'S DISEASES IN THE CHICAGO POLICLINIC. There are two distinct types of summer diarrhoea-the one with sour stools, the acid of sugar and starch fermentation proving to be an irritant to the intestinal membrane and causing the diarrhoea, and the one with putrid stools, from the decomposition of nitrogenous food, as meat, milk, eggs, fish, etc. The sour diarrhoea is not very dangerous, as the general system is not poisoned. The putrid diarrhoea is accompanied by the production of alkaloidal ptomaines, which invade the blood and poison the system, producing fever, convulsions, collapse, coma, and, if not successfully treated, death. In many cases where the stools are green, due to the growth of certain chromogenic bacteria, there is no general systemic trouble, but, on the other hand, where there are rather innocentlooking stools, nothing but a little rice water discharge, the patient is seriously ill. In every such case of cholera infantum there have always been putrid stools at first, and they are no longer putrid, simply because everything has been washed out of the bowel. My own experience is that brown stools are foulest in point of odor, and most apt to be accompanied by severe symptoms on the part of the general nervous system. Some of these patients have fever, and some have not, simply because in some instances poisons capable of producing rise in temperature are formed, in other instances they are not. Fever is then purely an accidental condition. Convulsions occur, but these are not due simply to the draining away of the serum which the large number of movements has produced, but to the production of a convulsive poison, something that can produce convulsions, something like strychnia. I do not say that strychnia is elaborated in the bowel, but a poison having a somewhat similar action. Another point of importance is the question of coma in these cases. Some years ago when I treated these cases exclusively by opium, I used occasionally to find a little one with what I considered opium poisoning. Later, after I had stopped using opium, once in a while the same kind of a case would occur. On questioning the mother I would find that no opium had been given outside of my direction, and something else must be at fault. I see several such cases *Read before the Chicago Academy of Medicine. every year, characterized by contracted pupils, stupor, sometimes coma, by slow respiration aud slow pulse. Now, there has been formed in the bowel of that child a poison which acts like opium and produces these symptoms. How shall we get rid of it? I have invariably given potash nitrate and water, and in the course of two hours, invariably profuse urination has occurred, and with it all symptoms have disappeared; in other words, the poison has been washed out through the kidneys. Here, then, is one of the symptoms which is evidently produced, so far as clinical information can teach us, from something developed in the bowel. Patients are troubled with insomnia, and it is likely that this sleeplessness is caused by poisons in the same general way. The patient is weak, the fontanelle has sunken, the eyes have sunken, the skin is cold and the pulse indicates collapse. Now to what is that due? Is it because the baby has had four or five or a dozen stools that day? No. If you had given the baby magnesia sulphate there would be the same loss of serum. Would the child be in that shape? No. There is another element there besides the number of stools. The mere number of stools is of secondary importance. The question of loss of fluid we have been taught to think much of-too much indeed. A motor depressant, say conium or curare, introduced into the child's blood, would have produced almost the same condition of collapse. It is evident that the collapse has been produced by some poison, and not simply by the number of stools that have been passed. If we believe the collapse to be due wholly to the number of stools we would most rationally proceed to stop the stools; we would give the child opium, tannic acid, or anything to stop the flow from the bowels. But if it be due to a poison that has been formed in the intestine, there is nothing to be gained by stopping the number of stools. We may even do damage by retaining in the bowel the source of the trouble. Summer complaint presents various phases, but due entirely to poisons formed in the intestinal canal. On the other hand; stools cannot produce poisons of this kind, but yet movements from the bowels occur, and we can only explain the phenomenon on the ground that products of acid fermentation are directly irritating to the intestinal mucous membrane, and act locally by stimulating the bowel, by increasing its functions locally. But remember that such irritations do not and cannot produce collapse; that they do not and cannot produce coma; that they do not and cannot produce convulsions; all the serious conditions are thrown to one side and only the local ones of increase in the number of stools and pain remain. Now then, here comes in the explanation of Dr. Rachford. If these depressed conditions occur, no matter what the number of the stools may be, the trouble is due to poisons formed from nitrogenous material. If we can stop the proteid fermentation, even if we have to leave an acid fermentation, we shall make a decided gain for our patient. It consists Now as to the treatment proper. of two general steps: First, to remove the cause; second, to repair the damage done. These two steps apply to almost any disease, but particularly to this one. First, remove the cause. How? We have found that the cause is due to certain fermentations going on in the bowel; let us get the poisons out of the bowel. How? By the use of laxatives first. Calomel in one-grain doses every four hours and copious hot water enemata (one quart at a time) are of most value. After cleansing the bowel, a good intestinal antiseptic should be administered to prevent further development of the trouble; calomel, one-tenth of a grain, and bismuth fifteen grains, prevent the germs from multiplying. Fortunately we have a much better means at our disposal. Suppose we have a diarrhoea and the stools are distinctly putrid, we know there has been fermentation, and that the germs producing it are living on proteid material; so keep that kind of material out of the bowel and starve the germs; there you have the keynote of the whole method of feeding. Starve the germs; do not try to get them out with chemicals. When the child has a putrid diarrhoea you must keep away from it all proteid material; keep away meat, fish, milk and eggs. Keep away those foods which are capable of undergoing putrefaction. Meat would not be given to a child of that age; fish would not be given to a child of that age; eggs would possibly be given, but milk would most certainly be given. Milk has been the chief diet of this child before it was taken sick, and the proteids of milk are what the germs in that intestinal canal are best adapted to live on. Above all things stop milk; the first thing to do in putrid diarrhoea. Do not be led into giving milk because the books tell you that it is a bland and non-irritating diet. That means nothing. We are not trying to save that bowel because it is in an irritated condition, but we are trying to prevent the formation of poisons, and therefore we will keep out of the bowel material from which they can be formed, and that is in this instance proteid material. Now, if we have to keep proteid material out what shall we put in? Anything which cannot support the obnoxious germs; anything which will starve them out and still be food for the child. The books tell us that in severe cases we should stop all food. If we stop all food we can certainly starve the germs, but it strikes me we are going to starve our little patient also, and put a strain upon him that is unnecessary. If we must take away meat, fish, eggs and milk, let us give him the starches and sugar. Many years ago Moore, of England, advised that these cases be fed on cane sugar exclusively. Such a diet is right; but you don't need to limit them to cane sugar; give them starches. I take a child six months old with putrid diarrhoea and give it arrow root, or rice, or crackers, or baked potato, but not milk. But you look surprised to hear me advocate potatoes and crackers-solid food in diarrhoea. When we have the theory of this disease that I have attempted to give you, that it is not due simply to an irritated condition of the bowel, why not give solid food? I assure you, from a personal experience of several years in this matter, that solid foods act most beneficially. Milk is a solid food; it is not liquid. It is only liquid before ingestion. The first thing that happens to it in the stomach is coagulation, so that it is probably more irritating from a mucous membrane standpoint than any amount of starch. We are told these babes cannot digest starch because they have no salivary secretion and no distinct pancreatic secretion. I will admit the physiological statement that their salivary and pancreatic secretions are both deficient, but I deny the other statement. It has been assumed that, because these two secretions are deficient, infants cannot, digest starch; but we all know of babies who have been given arrow root from their birth, and who have digested it perfectly, We all know that babies can and do digest starch; they do it daily. Why, there is hardly a secretion in the body but is capable of digesting starch so that it can be absorbed. Right here I wish it to be understood that I do not advocate starch as a con CHILDREN'S DISEASES. tinuous food for infants, but I am speaking of its use for temporary purposes; it does help that child along when it is poisoned; it does serve a purpose with that child when we want to take away other kinds of food, and in giving starch we have the advantage of not depriving that little one of all food. How about predigesting the starch? We do not need to predigest the starch; the great bulk of children can digest starch, particularly the small amount necessary for our purpose. I told you that milk was bad for this condition, but peptonized milk is worse. This preparation is generally bad. In the first place, it is peptonized by means of a pancreatic ferment. If you will experiment by putting some hard boiled egg in a solution of pepsin and hydrochloric acid, and leaving it over night at the temperature of the body in a suitable oven, you will find that it has not only digested completely, but that it has a peculiar odor that is not unpleasant; but take the coagulated egg albumin and put it with trypsin in an alkaline solution, and subject it to the same conditions, and you will find, as you open the incubator, that it has a distinct fæcal odor. If you leave it a few hours longer the fæcal odor will become stronger, and in a few more hours the odor will be unbearable The mass has become putrid. Now the action of trypsin upon proteid material is to break it up in such a way that the germs of putrefaction can thrive therein. They thrive readily in the products of tryptic digestion, but not readily in the products of peptic digestion. The milk partially peptonized by this pancreatic extract is only in a better shape to undergo putrefactive changes when it reaches the stomach and bowels. If you put it into a perfectly healthy alimentary tract, no harm will occur; but if you put it into a bowel that is already contaminated with putrefaction-producing micro-organisms, you have only helped those micro-organisms to the extent to which you have digested that food. Understand, I do not say that there are no conditions in which peptonized milk may prove useful, but am merely condemning its use in the putrid diarrhoea of infants. Sterilized milk is good as a preventive, but of no value to give during treatment. Milk from the mother's breast does as much damage as milk from any other source. Other things being equal, I would rather treat an acute case of diarrhoea in a bottle baby than in a breast baby, because I can give the bottle baby just what I 9 want to. Frequently I would take the baby from the breast for thirty-six hours, keeping up the mother's secretions by the breast pump, and feed the baby as I would like to; but we cannot always do this, and where I cannot do it I find that I do not get as good results in treating diarrhoea in breast-fed babies as in bottle-fed babies; I cannot cure them so quickly because I cannot feed them right. Such a procedure is only necessary in severe cases. How long is it necessary to withhold proteid food in acute diarrhoea? Twenty-four hours will usually suffice to correct the odor of the stools; at the end of that time stools which have been rotten will have lost their putrid odor, usually, and at the end of forty-eight hours they will certainly have lost their putridity. In chronic cases, where there is already ulceration of the intestine, the putridity is maintained by something besides the intestinal contents. Let us say the putridity has ceased, what will occur? Almost always the stool will become sour; in other words, an acid fermentation which has been going on in addition to the putrid fermentation continues, so that we still have left a cause for diarrhoea, but we have transformed a diarrhoea, which was capable of causing nervous symptoms, into one which is only capable of producing local symptoms in the bowel; we have transformed a dangerous trouble into one comparatively simple. That is what has been gained by the method of feeding. Remove the cause by purges, remove it by washing out the bowel, remove it by antiseptics, and above all by starving out the germs by withholding their proper food. We have removed the cause, how shall we repair the damage done? Ordinarily, with the removal of the cause, the child promptly recovers. But the matter is different in a severe case where the child has been seriously ill from a sharp attack of cholera infantum, and at the end of a few hours of illness is in a state of collapse; sunken eyes, sunken fontanelle, and pale, cold surface; rolling the eyes about, opening the mouth, showing the dryness of the lips, etc. What shall we do? Wash the bowel as far as it can be done for a double purpose, the one to remove from the bowel as much offending material as possible, although but little will be found; the other, to supply some of the fluids which have been lost. The water used should be as warm as can be borne. The peculiar depression must be combated by all possible means. First, by external heat in the shape of hot baths and hot blankets |