removed the pains of the phthisical patient, brought back a calm and reparative sleep without having recourse to any narcotic, an advantage the more appreciable, as the stomach was already fatigued by the extraordinary substances introduced into it. This sudden return to physical rest favored the re-establishment of all the functions, organic and mental, the drugs which had been previously vomited became tolerated, the nightsweats disappeared, the patient, whose temper became disagreeable, felt himself happy, resumed his former equable humor, works with ardor, and is able to climb several stories without being oppressed.

PARIS, April, 1888.

Translations.

UNDER THE CHARGE OF I. N. BLOOM, A. B., M. D., DERMATOL. OGIST TO LOUISVILLE CITY HOSPITAL, ETC.

MODERN TREATMENT OF ANEURISMS. (Scheele, Therapeutische Monatshelfte 1, 1888; Deutsche Med. Zeit., April 26, 1888.) Treatment of aortic aneurism depends (1) on the early diagnosis, (2) the seat of the aneurism, (3) complications and destructive relations to neighboring organs.

When recognized early as a deep-seated aneurism, the first indication for treatment is (a) absolute long-continued rest in a suitable position; the patient usually finds this himself, but often the physician must determine it from the subjective and objective symptoms; (b) application of ice; (c) attention to and limitation of diet (the minimal amount, after Tuffnell, being four ounces of fluid, consisting of milk, eggs, and cocoa, and five to six ounces of solid food), including diminution of the fluid ingesta. Then subcutaneous injection of ergotin, internal use of the iodine salts with the addition of opium until toleration is established.

If the aneurism has existed for a long time, as may be approximately inferred from the size and superficial site of the tumor, we must try galvano-puncture or ligature after Brasdor-Wardrop. The latter operation is also indicated when the arteria innominata is the site of the aneurism.

A NEW METHOD OF TREATMENT OF STRICTURE OF THE ESOPHAGUS.-(Leyden, Berlin, Idem.) At the congress at Wiesbaden, April 9th to 12th, Leyden spoke of a new method which he had used for a year. Small canulæ are placed in the strictures and remain there. Ninety per cent of esophageal strictures are caused by carcinomata; patients die of inanition. We can only prolong life a few days by rectal enemata. Esophageal sounds only give relief for a few hours, and are dangerous from the fact that the end of the sound comes in contact with the dilatation above the stricture, and prepares the way for perforation. Two methods of treatment are now in use designed to avoid this danger and effect a better method of sustenance. One the method which Leyden recommends, the other the surgical gastrotomy. The latter, employed quite frequently of late, has not been attended with brilliant results. In recent times English surgeons attempted to introduce permanent canule by shortening the sounds after their introduction. Leyden modified this in that he uses canule six centimeters (2 inches) long, which are introduced into the stricture by means of the sound. The deep-seated strictures of the cardia are accessible as well. In a very large number of cases the canula can be introduced and removed at any time by means of a thread fastened to it. In one case, where the thread broke, a patient carried the canula in situ ten months.

By its use death from hunger is averted, and patients can easily take fluid nourishment, such as milk, wine, cod-liver oil, eggs,

etc.

As a result of this treatment Leyden says that one patient lived ten months, although when first received she was in a very bad condition. She gained ten kilos (twentytwo pounds). Another patient gained twelve pounds in four weeks. Both lived ten months longer than they would otherwise have done. One patient, a woman forty-eight years old, died of kidney colic and fever ten months after the introduction of the canula. The autopsy showed pyelitis calculosa as the

cause of the fever. In the esophagus the canula was found movable, tolerably loose, not stopped up, and free from incrustations. There were no signs of necrosis from pressure on the neighboring cancerous portions. The dilatation of the esophagus above the stricture was not as great as is usual, and the carcinoma itself was not as large in extent. There was no sign of beginning perforation. The canule were as pervious as in the beginning.

In the discussion Leyden acknowledged that a certain amount of skill was necessary for the introduction of the canula. In one case it took him three days before he could introduce it after he had allowed a soft esophageal sound to remain some time. He believes that the canula, by preventing the ingesta from irritating the cancer by direct contact, lessens the growth and development of the tumor.

ACTION OF ERGOTIN ON INVOLUTION OF THE UTERUS. (Annales de Gynécologie; Journal de Médecine, April 22, 1888.) M. Blanc determined to solve definitely this question: Does ergot hasten or retard involution of the uterus? Most writers maintain that it hastens it. A small minority, among which are Fochier and Ganzenotti, held the contrary.

M. Blanc carried out his observations on ninety-two women, whom he divided into three groups. The first group, consisting of forty women, received no ergot. The second, consisting also of forty women, received ergot during the first five days folfowing delivery. To the third group of twelve women it was given until the tenth day after the accouchement. Ergotin was given in all cases by hypodermic injection. The first injection was given immediately after delivery, and was repeated once or twice, as occasion demanded, until the uterus was firmly contracted.

In order to obtain with scientific accuracy the modifications in volume of the uteri, which were and were not under the influence of ergotin, M. Blanc took daily external measurements of the organ, and twice

(on the fifth and tenth day) intra-uterine measurements. The site of the fundus of the uterus was marked on the abdominal wall, and the distance from it to the symphysis pubis represented the height of the uterus. To determine the breadth he fixed the boundaries of fundus with one or two fingers of each hand and measured between them. For intra-uterine measurement he used a large sound with the curvature somewhat more accentuated than ordinarily. Catheterization was practiced under the most minute antiseptic precautions. M. Blanc, as the result of these careful observations, has formulated the following conclusions:

1. Ergot administered for five or ten days after confinement exercises no favorable influence on involution of the uterus.

2. A sufficient number of observations were made to show that it retards in a measure the regular contraction of the

uterus.

3. This fact, proved by extra and intrauterine measurements, contra-indicates the employment of ergotine as an agent in hastening uterine involution.

4. It is properly used in secondary hemorrhage. Its action will be more efficacious the earlier it is given after confinement.

Abstracts and Selections.

NOTES ON THE TREATMENT OF ACUTE TONSILLITIS IN CHILDREN.-When an inflammation attacks the tonsil, it is influenced in its progress by those constitutional states that so markedly affect the natural history of disease. Hence, it is important to recognize the presence of syphilis, tuberculosis, rheumatism, etc., in the constitution of any patient we may be treating for a tonsillitis.

In children these diseases may be latent, but none the less they have a potent influence over the course of the malady under consideration. Therefore, we should always make ourselves familiar with the natural history of the parents, and, if any of these diseases are found, so modify our treatment as to meet and counteract whatever of baleful influence may have been transmitted to the child.

In the suggestions to follow, on the management of an acute tonsillitis in children, it must be understood that no routine practice is proposed. The plan detailed must be so modified as to meet the hereditary and acquired variations from health in the particular case under consideration.

In order to obtain a clear idea of what is required in a rational treatment of a tonsillitis, let us see how an inflammation may behave when attacking that organ. In our opinion, there has been too much refinement in this matter. Bearing in mind its anatomical structure, we observe, in the first place, that an inflammation may limit itself entirely to the tissue immediately surrounding the tonsil, and then we have the peritonsillitis of some authors; it may express itself in the superficial parts, and become the erythematous tousillitis of others; it may be deep-seated, involving the parenchyma, and we have the parenchymatous tonsillitis, or the true quinsy of the older writers; and again, the brunt of the inflammation may be confined to the lacunæ, and then the disease is called folliculous tonsillitis. Now, in our opinion, this is the same inflammation modified according to the constitutional state of the patient, the kind and severity of the exposure, and so on. As an illustration, it has been observed that the variety of tonillitis, called parenchymatous, occurs with great frequency in rheumatic subjects, and treatment followed in recognition of this fact-as the exhibition of the salicylates, salol, etc. -has resulted in prompt relief. Other instances could be cited in proof of this position, but it would carry us too far from the immediate purpose of this paper. The question before us is, how to treat a case of simple tonsillitis, by which is meant one uncomplicated by any other disease, and uninfluenced by the presence of any diathesis. Such cases are not rare, and, in our opinion, can be greatly modified in their duration and severity by proper treatment.

We have to deal with a sthenic inflammation-one that develops very rapidly, and continues at a great height for some days. The plain indication, then, is to control the production of this heat, to so influence the nerve centers as to make a high temperature impossible. This is done by the exhibition of antipyretics. So much for the general treatment. The next indication is to relieve the local distress. When the mucous membrane of the mouth and throat is inflamed, the secretion therefrom is highly acid. This acid secretion acts, in time, as an irritant, and keeps up the local disturbance.

The

indication is to apply alkalies to the surface of the tonsil, to neutralize the acidity of the secretions, and relieve the inflamed surface of this great source of irritation.

This is the general plan proposed; the details of its application are as follows:

The doses given are for adults, for the reason that we then have a definite standard to go by, which can be modified to meet the age of each individual case.

First, to keep down the temperature.

The various antipyretics may be used according to personal choice, but we have come to rely principally upon antifebrin. This is to be given in five-grain doses every hour until the temperature falls to nearly normal, and then at intervals necessary 10 prevent it rising again. We have never been obliged to give more than three doses in order to accomplish the first indication; generally two doses have been sufficient. In children, the minimum dose according to age should be given, and the patient carefully watched. Occasionally it will be found to have a depressant effect, and must be abandoned for one of the other antipyretics.

The local treatment can be applied in several ways. Bicarbonate of sodium can be dusted upon the tonsils by means of an ordinary powder-blower, or a solution, ten grains to the ounce of water, can be sprayed on the parts by means of an atomizer, or, where the patient is of sufficient age, he can be instructed to dip the finger into the powder and touch the surface of the tonsil with it, or he can hold the solution in the mouth, allowing it to bathe the parts for a few moments. This local treatment should be used frequently, say at intervals of an hour during the day.

Our notes show that, with this plan of treatment, four cases of severe tonsillitis, seen within the last few months, were limited to two days each. On the third day there remained simply the general malaise which is apt to follow cases of this kind. The temperature of these, when first seen by the writer, ranged from 102° to 104° F.

Professional friends, to whom this treatment was suggested, have reported equally good results. It is not necessary to report these cases in detail, but we content ourselves by formulating the conclusions of this paper as follows:

1. When an inflammation attacks the tonsil, it is greatly influenced in its course by the presence of any diathesis.

2. The treatment must be so arranged as to meet and counteract the influence of this diathesis.

3. In all cases, simple as well as complicated, the general indications are to keep down the temperature and relieve the local irritation.

4. The first indication can be met by the exhibition of antifebrin in proper doses; the second by the frequent application of bicarbonate of sodium, either in powder or in solution, to the surface of the tonsil.

5. This plan, properly followed, will generally limit the disease from one to three days. Dr. F. H. Potter, Buffalo Medical and Surgical Journal.

OERTEL'S RECENT STUDIES IN Diphtheria. There are few diseases which present so many points for inquiry as diphtheria, the modern scourge that seems to have taken the place of typhus and smallpox in civilized humanity. It spares neither young nor old; but it is the young who suffer most. It cruelly robs many a household of the flowers of the flock, and leaves behind it a lasting sorrow. Who does not know of families that have been thus desolated? Nay, the tale of victims to this modern Moloch includes many of the noblest of our own profession, more often the young and energetic, who succumb to disease contracted in discharge of duty. How grateful, then, will the world be for any clear indication of means for the mitigation of this scourgefor any light shed upon its etiology and its nature whereby the hands of Medicine may be strengthened in its endeavors to cope with the disease. For, in spite of many inquiries into epidemics of diphtheria, its etiology yet remains obscure. It is commonly believed to be a "filth disease," and there are many instances, both in town and village, where defects of drainage have been associated with outbreaks of diphtheria. Again, its propagation through infected milk has often been traced, and it was conjectured to be transmitted direct from the cow long before the notion of scarlatina being so transmitted occurred to the mind. That

it can not be generated de novo is in accordance with all that science has taught us concerning the origin of the disease; yet many a practitioner could give examples which seem to leave no room for any other couclusion, while it is notorious that the line between tonsillitis and diphtheria is often very finely drawn.

The recent elaborate inquiry of Professor Oertel, of Munich, of which we have given an account in these columns, seems to have advanced our ideas upon the nature of the disease one step, although it leaves its etiol

ogy still in obscurity. It is true, doubtless, that the conclusions at which Professor Oertel has arrived are much the same as those which are now generally held; but his great merit lies in this, namely, that he has given such conclusions that basis of fact which was heretofore lacking. We have therefore now a clearer insight into the nature of the morbid process, and can with greater confidence deal practically with the disease. The main outcome of Professor Oertel's work is as follows; Diphtheria is a disease which is excited by a specific contagium. This contagium-by analogy rather than from absolute demonstration-is of bacterial nature. The implantation of the contagium upon a mucous membrane, usually that of the fauces, leads to changes commencing in the surface epithelium. It is inferred that the virus, probably a ptomaine, at once acts upon the mucous membrane, exciting inflammation, as shown by the leucocytal infiltration that occurs. The leucocytes themselves become attacked by the virus, and undergo remarkable changes which lead to their disintegration. These changes, which have been so exhaustively studied by Professor Oertel, are marked by abnormal cleavage and chemical alteration of the cell-nuclei; they eventuate rapidly in the formation of areas of necrobiosis in the substance of the mucous membrane. The diphtheritic false membrane is therefore but a part of a process that involves the whole mucosa. The lymphadenitis in connection with the altered mucous tract is strictly specific, for the glands show the same changes as to necrobiosis as the membrane itself. Similar lesions, but less intense and numerous, occur in the intestine and the mesenteric glands, and also in the spleen; but in other viscera the lesions are referable to inflammatory reaction rather than to the essential phenomena of the disease. The study is a demonstration that diphtheria is at the outset a strictly local disease, but that in a few hours its poison spreads in the part first affected and in its vicinity; and in a few days it may enter the blood in such amount as to produce the most marked evidence of systemic poisoning, which, if not causing death from its effect on the heart or other vital organs, may in due course produce peripheral neuritis, and perhaps myelitis.

Diphtheria, then, is not in the first instance a systemic poison; it is local. Just as in syphilis the attempt has been made to prevent the constitutional malady by excision of the local contagious sore, or in hydrophobia by excision of the bite-wound, so in

diphtheria it might be thought that the disease could be arrested by dealing with the local manifestation thoroughly. This conception has been largely put in practice from the earliest days of the history of diphtheria, and the false membrane has been ruthlessly destroyed only to re-form. This period of the violent escharotic or other means of removal of the false membrane must be closed. Milder solvents are applicable; but, if Professor Oertel be correct, the object they aim at is unattainable. The membrane may be dissolved and detached, but the disease is not cured; for the membrane is only the surface indication of a deep-seated and wide-spread change. Nevertheless, it is well to minimize the risk of the extension of the disease by contagion within the body by the free disinfection of the pharynx. As for other treatment-for we have no antidote for the diphtheritic poison-reliance must be placed upon nutrition being maintained. How impotent such conclusions make us feel! Yet what is said of diphtheria is applicable to many diseases, perhaps all of the specific fevers; and, being true, it should make us endeavor all the more to unravel the mystery of their origin, so as to prevent the occurrence of plagues that we can do so little to stay. The "people perish from lack of knowledge," and in these diseases it is too often the young and promising who are snatched away, for they are less able to resist the virulent poison that destroys the cells which compose the body. Lancet.

TUBERCULOSIS IN CATTLE AND IN MAN.— There has long been an impression abroad that the acknowledged prevalence of tuberculosis among cattle, and the frequent occurrence of the disease among milk-giving cows on dairy farms, constituted a public danger of some indefinite kind; but the hope has been indulged that this danger was, after all, more apparent than real. Certainly, the existence of tuberculosis in cattle and other animals is not usually regarded by authorities as by any means a common cause of tuberculosis in man. Some very startling and disquieting statements on the subject appear, however, in a report issued by Principal McCall, of Glasgow Veterinary College, on "Tuberculosis in Cattle, and how to deal with it," intended to "open the eyes of the authorities and the public to the gravity of the position in which they are placed." He gives a general account of the disease and of the means whereby it has been experimentally propagated among the

lower animals, adopting formally the bacillary theory of its origin and the identity of the bovine and human varieties, and asks, "Is it not but reasonable to conclude that bovine tuberculosis is frequently transmitted to the human subject by eating the flesh and drinking the milk of tuberculous cows? It is to be hoped that thorough boiling of the flesh destroys the vitality of the bacilli; but we are not warranted in believing that roasting the flesh, as usually practiced, will have that effect, and, as milk is seldom boiled before being partaken of, it is clear that the milk of a tuberculous animal is unfit for human or other animal food, and dangerous to life." Principal McCall thinks the disease among animals is alarmingly on the increase, and unless vigorous repressive measures are adopted it will become more wide-spread. "It is clearly the duty of all local authorities to do all in their power to induce the Government to include tuberculosis in cattle among the other scheduled diseases, and to grant compensation, as in contagious pleuro-pneumonia. I regret to have to confess that there are few towns in the three kingdoms, if any, where there are as many tuberculous and emaciated animals publicly exhibited and sold in open market as in Glasgow, and the reason, I apprehend, is that the persons who traffic in them are not sufficiently punished by confiscation of carcasses, and that it pays them to feed the inhabitants of Glasgow and the West of Scotland on the abominable carrion." These are somewhat alarming statements to come from one in Principal McCall's position, and they add one more terror to the milk-can, in which we have been already taught to dread the presence of scarlet fever and typhoid.-Ibid.

TUBERCULAR NECROSIS OF CRANIAL BONE LEADING TO PERFORATION.-The rarity of this disease appears to justify the publication of a note of the following case:

L. P., a girl aged seventeen years, came under my care recently as an out-patient, suffering from an ulcer over the right side of the frontal bone just in front of the coronal suture, a little above the level of the orbit. The edges of the ulcer were widely undermined, and its base was covered with a thin layer of pus, which pulsated synchronously with the heart, while on coughing a drop or two of pus was forcibly expelled from the deeper parts. Several sequestra, mostly about the size and thickness of a threepenny piece, were removed, a nearly circular aperture then existing in the bone of