and it disappears yet more rapidly with the disappearance of the endocarditis. Should both the dilatation and the endocarditis become chronic, hypertrophy would result. Differentiation of myocarditis from valvular disease can be made without difficulty. The most important factor in differentiating between endocarditis and myocarditis is the general phenomena. The sudden loss of strength, the anxious expression, the small, arhythmical and very rapid pulse are not found in endocarditis, neither is there any local pain. A restoration of heart force is also more decided and more speedy in the latter than in the former. Myocarditis is occasionally associated with endocarditis and pericarditis, but the extent of the disease can seldom be ascertained during life.-A. F. C., Archives of Pediatrics. ON STOMACH FLATULENCE IN HEART DISEASE. IN NO. 4 of his papers on the "Effects of Moderate Drinking on the Human Constitution," Dr. George Harley calls attention to the danger attending flatulent distension of the stomach in heart disease. He conceives that this may sometimes be the immediate cause of sudden death in such cases "from the winddistended stomach pressing up the diaphragm against the apex of the heart, and so impeding its movements in its weakened state as actually to arrest them altogether." As applicable to certain cases, this view of Dr. Harley's receives my assent; but I have long entertained the belief that the same trouble (flatulence) may occasionally bring about the same disastrous result in a different, and, indeed, opposite way, namely, by the abrupt discharge of large volumes of wind, entailing a sudden fall of pressure in the vascular system, and with it fatal cardiac syncope. I recollect, in the early period of my professional career, a young student in Paris, who, after walking about a good deal during a very hot July day, entered a café with a confrère. Feeling languid and tired, he soon quitted it to return to his lodging. He had hardly proceeded half a dozen yards from the door when he tout a coup fell insensible to the ground as though he had been shot. The passers-by picked him up, and in a minute or two he was himself again. The attack was regarded by an interne of M. Bouillaud, who happened to be at hand, as one of petit mal. The real fact, however, was, as I have good reason to know, that it occurred at the moment of eructating a large volume of gas from the stomach (without any attendant nausea or vomiting), and the sudden withdrawal of pressure caused temporary failure of the heart's action. Taking into account that this same student is now over sixty, and that he has never had any such experience or other cardiac symptoms since-just, indeed, as he had never had any such beforeit can admit of little doubt that his heart on this occasion, through of course not unaffected by the fatigue and other relaxing influences that had preceded, was quite healthy, structurally and texturally, and his arteries elastic, and so matters soon righted themselves; but had the case been otherwise-that is to say, had he been the subject of any considerable heart disease there can be just as little doubt, I think, that such failure of its action might have proved fatal. I need not say that the danger referred to here is practically recognized in the gradual compression of the abdomen with a flannel belt during tapping for ascites-this being intended, indeed, as a safeguard against it. The only difference is that in the one instance we have to deal with fluid, in the other with gas. For obvious reasons the danger would be greater in the erect posture. Though in course of practice I have not been without evidence confirmatory of the view above enunciated, such views are, as Dr. Harley seems to admit in reference to his own, by the conditions of the case, not very susceptible of proof. But neither are they very susceptible of disproof; hence, in presence of the vital interests at stake, they may claim some share of consideration. Assuming their correctness, the sufferer from heart disease would seem to be placed, in regard to his flatulent troubles, very much between Scylla and Charybdis; and the practical lesson deducible, I think, should be to prevent as far as possible, by appropriate medicinal and dietetic treatment, the production of flatulence, rather than to trust to any voluntary efforts on the part of the patient to get rid of it after it has arisen.-Dr. H. F. A. Goodridge, London Lancet. RECTAL CONCRETION.-The results of constipation are well known and only too frequently brought to the recollection of members of the profession, but I think the following case presents some points of rarity which may justify its publication. A. B., an old gentleman aged seventy-six, called on me on the evening of November 28, 1887, complaining that "he wanted to pass something, but could not." His anxiety for relief was so great that he did not indicate whence he wanted to pass something. After some cross-examination, I elicted "that the bowels were habitually constipated, but that he certainly had passed nothing for (he said) three days; that something was trying to come away from his bowels now, but could not come; could I help him at once?" After some little trouble I obtained his consent to examine his rectum, which I found blocked by a fecal concretion quite as large as a fetal head at full time, and bearing downward by ineffectual attempts of the rectum to evacuate its contents. I elicited from him that he had made a long railway journey that day, and presumably the motion of the train had excited to feeble action the languid or partially paralyzed nerves of the lower intestine, which set up the irritation from which he was suffering. I explained to him that the speedy relief he desired was not so immediately attainable from medicine as by the mechanical effects of a lavement, to which, after some considerable hesitation, he assented. On account of its great size there was some difficulty in reaching beyond the upper end of the scy balon to wash it away, but after some perseverance and assistance the rectum was evacuated, and he expressed himself happy and comfortable. The points to be observed in the case were, the great elasticity of rectum, which permitted its walls to be dilated so far in excess of their ordinary caliber; and the stimulus given to the sluggish rectal nerves by the motion of the railway. We are freely conversant with the effects of railway traveling on the bladder, which was alluded to in some admirable papers in the Lancet on Railway Traveling some years since; but I have never come across any allusion to its effects on the rectum by exciting it to action, and should be glad to learn the experience of others in the matter.-Dr. J. I. Mackenzie, Ibid. A RARE CASE OF PUERPERAL FEVER.-At 2:15 A.M. on February 1st I was called to attend Mrs. T. in her second confinement. The child was born before my arrival, and the placenta removed shortly after. On the afternoon of the third day the temperature rose to 102.5°. The discharge was good and free from offensiveness; milk was scanty. The uterus was at once thorougly washed out with a strong preparation of "Condy" water, and a two-grain pill of quinine given every two hours. The bowels acted freely. In the evening the temperature rose to 103.2°, and the uterus was again irrigated On the following morning (fourth day) the temperature was 103.8°, and and the pulse 114. I had suspicions that the hyperpyrexia was due to imperfect sanitation in the house. I subsequently found that a water-closet was situated immediately behind the patient's bedroom, with one over it on the second floor, and one under it on the basement. A faint smell was perceived (or fancied) arising from these. The patient was removed into the front room on the same floor. The temperature in the morning for the next seven days varied from 104° to 104.5°, and in the evening from 101° to 102°. The weather was very cold and windy during this week, consequently the house was closely shut up each night. The morning exacerbation was undoubtedly due to the patient breathing this pent-up atmosphere; for in the evening, after the doors (and sometimes the windows) had been opened during the day, the temperature was always lower. For some reason or other the patient was not removed out of the house into more wholesome quarters until the eleventh day. On the first morning in her new abode the temperature was 99.8°. On the afternoon of the fourteenth day she fell into a deep comatose state. The temperature was 990; pulse 114, jerky and somewhat compressible. Her teeth were clenched, and her lips compressed. She failed to reply to any irritation, and refused even a drop of fluid from a spoon. There was complete unconsciouness. The urine was passed involuntarily. The skin was dusty, the breath sickly, and the tongue, when last seen, thick, dry, with a parchmentlike covering, having a deep-branched crack down the center, looking like a fresh wound. She lay in this unconscious state without food for thirty-seven hours. At about 4 A. M. of the sixteenth day, she opened her eyes and spoke a few words to her husband, and drank a little milk. I saw her six hours afterward, when she spoke freely and drank easily, but had no recollection of the previous two days. Temperature 99°; pulse 102; skin rather dry; tongue as before; urine pinkish, with distinct ammoniacal odor, and one tenth albumen. On the following day she had a similar relapse of unconsciousness, but not for so long. On the twenty-first day she showed marked improvement, and gradually recovered her usual health. Dr. T. P. Harvey, Ibid. THE LIFE HISTORY OF FILARIA SANGUINIS HOMINIS.-It is interesting to note the long chain of inductive reasoning, combined with careful and laborious research, which has led to the unraveling of the complicated life history of the filaria sanguinis hominis. The discovery of bilharziac hematuria by Griesinger in Egypt led Wucherer to search the urine of patients suffering from hematuria in Brazil, and it is just twenty years since he first saw the immature worm in the urine of these cases. Shortly afterward the same parasite was independently discovered by the late Dr. T. R. Lewis in the blood of a patient in Calcutta, and to this acute observer is due the credit of establishing a connection between chyluria and the filaria. This observation led Dr. Manson to the surmise that the adult worm must establish itself in such cases in the larger lymphatic vessels, or even in the thoracic duct. Systematic search was consequently made; but it was not until 1876 that the adult was at length found by Dr. Bancroft, of Brisbane, who went a step further by suggesting that the mosquito was probably the intermediate host. This Dr. Manson proved to be correct by direct observation in 1877; the immature filaria is sucked up with the blood by the mosquito, which shortly resorts to water to deposit its eggs, and, having achieved this object of its existence, expires; not, however, before it has digested the greater number of the filariæ. A few, however, escape, and are set free by the dissolution of the mosquito. It has been supposed that the filaria passes the next stage of its existence in the water as a free hematode, but can only attain full sexual development by entering the human body; it is believed to accomplish this by penetrating the skin of bathers, and to attain sexual maturity in a short time within the body, the conjunction of the sexes taking place in the lymphatics. Lewis once obtained a fragment of a male which was closely coiled around the female; but the specimen described by Professor A. G. Bourne, of Madras, from a case of lymphoid scrotum, is the first found in a condition which permits the specific characters to be described. The chief point which now remains to be cleared up by observation is as to the manner in which the parasite enters the human body. Dr. Manson has proved himself on former occasions not only an able observer but an acute reasoner; still his theory mentioned above presents certain obvious difficulties.--British Medical Journal. EFFECTS OF EXPOSURE OF THE INTESTINES. At the November meeting of the Berlin Obstetrical and Gynecological Society, Professor Olshausen read a communication on a hitherto unrecognized cause of death after laparotomy, where intestine has been allowed to lie outside the abdominal wall for a prolonged period. In this country, at least, surgeons are careful to prevent prolapse of the intestines. Coils which adhere to a tumor and can not be at once separated are carefully covered with flat sponges, or with towels wrung out in hot water which often contains an antiseptic compound. As soon as the adherent coils are separated from the tumor, all bleeding points being secured, they are carefully replaced. As soon as the tumor is extracted through the abdominal wound, or indeed while it is slipping out of the incision, a broad flat sponge is slipped into the peritoneal cavity to prevent any chance of prolapse, and to protect the gut from the sutureneedles. The abdominal incision is, moreover, always made as short as possible, so as to avoid the sudden escape of coils of intestine. The Germans are less particular about eventration. Dr. Martin, in 1885, publicly recommended the dragging out of a large amount of intestine in cases where the tumor lay deep in the abdominal cavity, and declared that the greater part of the intestinal tract might be left hanging out of the abdomen during the whole operation, so that the surgeon might have plenty of room for manipulating the tumor. "This eventration," said Dr. Martin, "is quite free from danger; I have practiced it in at least ninety per cent of my cases without seeing any evil results." Professor Olshausen was more cautious, and directed attention to certain cases of collapse, often fatal, which followed cases of abdominal section and were not accompanied by symptoms of peritonitis. He concluded that prolonged exposure of the intestines in laparotomy might cause disturbance in the circulation in the walls of the gut, ending in venous stasis and serous infiltration, with ultimate formation of ecchymoses. At the same time the muscular coat is paralyzed, often for several days; if the paralysis does not abate, symptoms of ileus set in. Fatal results of this kind are probably caused by the absorption of decomposing material in the intestinal canal. Ibid. CINERARIA MARITIMA IN THE TREATMENT OF CATARACT.-A member of the profession, in a letter addressed to the Superintendent of the Botanical Gardens, Trinidad (published in the Pharmaceutical Journal of this week), asking for a supply of the juice of Cineraria maritima, gives a wonderfully interesting account of its curative effects, and its therapeutic action in the treatment of cataract. It appears, from the letter, that Dr. Mercer, the gentleman referred to above, formerly practiced his profession at the Port of Spain. Six years ago he came to London, and submitted to the right eye extraction. This operation appeared to be a failure, and at the same time the cataract in the left was rapidly advancing, so much so, that he at once decided on returning to his friends at Trinidad. There a friend persuaded him to make trial of the juice of a plant ex tolled by the natives Cineraria maritima. Being, he says, without any hope of saving even a glimmer of sight, he at once assented, and commenced by instilling a drop or two into each eye three times a day. It proved most efficacious, and "whereas he was blind," in the course of a few weeks he was able to see and read the hour of the day by his watch. The improvement in four weeks was very marked, and he can now count fingers with the eye operated on, and which he thought was wholly lost. All this has come about in the short space of two months. The application produces no irritation beyond a slight burning sense of pain which lasts only a couple of minutes, and is followed by a profuse lacrymal discharge. The juice of the leaves of the matured plant acts better than those of a younger growth, but there appears to be some difficulty in keeping up the supply, and consequently the superintendent of the Botanic Gardens, Trinidad, has thought fit to communicate this to Mr. Thiselton Dyer, Director of the Royal Gardens, Kew (the son of a late much respected member of the medical profession), and who will doubtless see the want speedily supplied. London Medical Press. RUPTURE OF INTESTINE WITHOUT EXTERNAL WOUND.-Before the Clinical Society of London, May 25, 1888, Mr. H. W. Page reported the following: A man, aged fifty, over whose right iliac region a cab had passed on the morning of April 5th, and who was admitted into St. Mary's Hospital the following day in great pain, and with very marked collapse. Rupture of intestine was diagnosed, but the amount of collapse seemed entirely to forbid laparotomy. There was no improvement during the day, and he died the next morning, forty-four hours after the accident. A rupture of small bowel was found four and one third feet above the ileo-cecal valve, and in addition to some smaller contusions in the cecum and neighboring ileum and much mesenteric extravasion, there was a knuckle of deeply congested gut an inch and a half in length. It is thought that even if laparotomy could have been done soon after the accident, when diagnosis probably could not have been at all sure, and the ruptured portion had been satisfactorily dealt with, this other piece of bruised intestine could hardly have been left alone. The danger of leaving it, viz., of secondary perforation from sloughing, is by no means imaginary, as is shown by the history of the second case, that of a lad, aged eighteen, who was butted in the belly-left iliac region-while at play with some other boys. He instantly had intensest pain, and when admitted to St. Mary's, sixteen hours afterward, on July 27th, gave a history of incessant vomiting since the accident. There were external signs of severe contusion, and marked evidences of local peritonitis to which his symptoms were regarded as due, but there was nothing specially suggestive of perforation, or of need for opening the abdomen. Opium was accordingly given, and during the next three days there was undoubted improvement. On the night of the 30th, however, there was sudden and alarming collapse. He rallied from this, and for three days seemed doing well again, but on August 3d collapse returned. From this there was no decided rally, and he died on the 6th. Necropsy revealed extensive hypogastric peritonitis and offensive pus in the left iliac fossa, where the blow had been sustained. A perforation was found in the small intestine in the center of a deeply congested sodden portion. This opening had thickened edges and was surrounded with lymph. It is believed that this perforation occurred only on the fifth day after the accident, as the result of the sloughing of a portion of severely congested gut, and the author points out that had laparotomy been done when the lad first came to the hospital, no more difficult question could well have presented itself than that of determining whether this contused piece ought or ought not to have been resected. In neither of the cases is it thought that the chances of successful laparotomy were any thing but the very poorest, but yet, as laparotomy alone gives hope of life, it is perhaps right to operate, even though gravity of symptoms and uncertainty in diagnosis seem to forbid it. It must be rare to meet with cases of abdominal injuries where there is no complication of any kind, or in which a simple rupture in one place is the only lesion, and these are considerations to be borne in mind when laparotomy is undertaken or entertained.—Ibid. INTRA-PARENCHYMATOUS INJECTIONS OF OZONE WATER FOR CANCER.- Dr. Joseph Schmidt (Wiener Med. Presse), of Aschaffenburg, has employed in two cases intraparenchymatous injections of ozone water for cancer, and has obtained such surprising results that he seems induced to submit this method of treatment to a further trial. According to the Münchener Med. Wochenschrift, No. 16, 1888, the method consists in the injection of ozone water in the strength of one to three grains to a quart of water. The injections were made with a Pravaz's syringe. The number of injections varied, according to the size of the affected area, from one to ten or more a day. They were made into the mass of the cancer itself, as well as into the healthy tissue bordering on it, and even into the swollen and suspicious glands. The pain when the injections are made with a rather dilute solution is not very marked, and disappears completely after several minutes or half an hour. Frequent local symptoms, especially when the injections are made with rather strong solutions, are, after a short time, moderate edema and slight redness and tenderness to the touch. These symptoms disappear in a few hours when the weaker solutions are used, but when the stronger solutions are used they last for several days. During the progress of this treatment the cancerous ulcers become cleaner, smaller, and cicatrize. The cancerous nodules grew smaller and gradually very hard, so that the introduction of the needle was often difficult, and was accompanied with a grating sound. In such places but a few drops could be injected with difficulty. After treatment had been continued some time, the parts, which at the beginning were swollen, became peculiarly dense, tense with edema, of a bluish-red color, and tender to the touch, as well as pain ful. When such parts were cut, under the skin, which appeared normal, was seen an edematous, cellular tissue, and under this a thick, dense, callous mass. The microscope revealed but very few nests of cancer cells. When this treatment was continued longer, the swelling receded and a connective-tissue shrinkage occurred. Bad consequences from the injections were never noticed.-Medical and Surgical Reporter. ANTIPYRINE IN CHOREA.-In the clinic of Dr. H. C. Wood at the Hospital of the University of Pennsylvania, both antipyrine and antifebrine have been used in a number of cases of St. Vitus's dance in children, and the results so far have been uniformly good, sometimes remarkable. Thus recently a case was shown to the class in which a week's treatment had produced almost complete quiet, although just previously there had been no decided improvement after three weeks' administration of arsenic. No difference has been detected in the action of antifebrine and antipyrine. In a recent communication to the French Academy, M. Legroux stated that he had had remarkable success with antipyrine in chorea, affirming that he has been able to reduce to a period of from one to three weeks (many of his cases getting well in a week) the duration of a disease which ordinarily lasts from sixty to ninety days. His treatment is as follows: One gram (fifteen grains) of antipyrine is dissolved in twenty grams (five drams) of syrup of bitter orange-peel, and the whole is administered at one dose. Three such doses are given during the twenty-four hours. He considers it perfectly safe to give this dose to a young child, and all of Legroux's patients are now treated in this way. In Dr. Wood's clinic much smaller doses than those used by Legroux have been used, and we are not at all sure that it is safe to give a young child forty-five grains a day. Therapeutic Gazette. THE TREATMENT OF INFANTILE CONSTIPATION. In cases where the passages are dry and hard, cascara has failed most signally, and that too after a most patient and thorough trial of the drug. In these cases, where there is a deficiency in the intestinal juices, I can most heartily commend to the consideration of the profession the use of small doses of podophyllin. For a babe from nine months to a year old, I would prescribe the following, to be used for at least two weeks, and longer if found necessary: Resina podophyl.................................. Sacch. lact.. gr. ij; 3 ss. M. et ft. chart. No. xxxij. Of course the proper dose can only be determined by trial. My aim is to produce a soft and easy discharge every day. And right here let me insist on the importance of appointing a regular time to have the bowels moved. Nothing should turn the nurse aside from attention to this most important duty. It is truly remarkable at what an early age an infant can be taught what it means to be placed on his little chair. I have often known mothers to commence to educate their babes in this direction as early as the fourth month.-Kansas City Medical Index; Analectic. |