We see, therefore, that the great danger in heart disease during pregnancy and labor is due to venous engorgement; and since this engorgement occurs in all heart lesions, therefore the danger is present in them all. We have seen, however, that mitral stenosis, when slight, produces this condition, while mitral incompetence must be more marked, and aortic disease even more so than mitral incompetence before, it appears; in other words. while all the various heart lesions produce the condition, its appearance depends upon the extent to which each one has advanced, so that we may say that the danger in heart disease depends rather upon the extent of the lesion than upon its nature.

No mention has been made of certain other accidents which may occur during pregnancy in heart disease, viz, the growth of fresh vegetations or the supervention of ulcerative endocarditis, since these may occur equally in all the lesions, and do not concern the point which I wish to bring out to-night; neither have I considered those cases where death occurs later on during the puerperium from pulmonary complications, since these belong to an entirely dif ferent category.

A few words may be said as to the treatment of these cases, and in the first place as to the use of cardiac tonics. These should be avoided as long as possible, and never be used until there are evident signs of failure of compensation. Before this appears, careful diet, moderate exercise, and the use of iron and arsenic are all that are required. As soon as compensation threatens to fail, cardiac tonics act well, as a rule (except in certain cases of mitral stenosis, where they often have no effect). The best of them is, perhaps, strophanthus in small doses (for example, M 23 of the tincture every four hours). It must be remembered, however, that prolonged use of these drugs after compensation has been restored tends to do serious harm, since the hypertrophy of the heart which they produce is followed by degeneration of its muscular fibers. The dose may be increased, if necessary, and then gradually diminished again until, eventually it may perhaps be dis continued altogether for a time. Strophanthus is especially useful where there is continued vomiting due to gastric congestion, and its own tendency to produce sickness may be counteracted by giving it with tr. cardamom co. If the venous congestion becomes very marked during pregnancy or labor, bleeding may in some cases give relief, at any rate for a sufficient time to enable the labor to be completed, and so allow the heart to again regain its power. Nitrite of amyl might perhaps be of use here, just as it was found useful by Dr. Fraser

Wright during the third stage of labor. Since the bearing-down pains tend to increase the venous engorgement, chloroform should be given as soon as ever they appear, and the second stage of labor should be reduced to the shortest possible time. The administration of chloroform should be continued until after the placenta has been delivered.

When Dr. Wright brought under the notice of the Society the case where he used nitrite of amyl in the syncope which followed the delivery of the placenta, some difficulty was found in understanding how it could relieve the engorgement of the heart. The following explanation seems to me, however, to be a reasonable one: The sudden delivery of the placenta causes, as we have seen, an extra amount of blood to be thrown into the right side of the heart, since the abdominal veins are already overdistended. Nitrite of amyl dilates the arterioles and lowers the blood pressure, so that more blood would tend to pass into the systemic veins, and thus engorge the right side of the heart still further. The veins, however, are already overdistended, so that no more blood can enter them, and hence no harm can be done thus by the drug; but at the same time the nitrite of amyl dilates the pulmonary arterioles as well as those of the systemic circulation, and hence the flow of blood through the pulmonary vessels is made easier, and the right side of the heart can empty itself, and gets relief. Hence we see that the important action of the nitrite of amyl in these cases is upon the pulmonary and not upon the systemic arterioles.-Dr. G. O. C. Mackness, Edin. Medical Journal.

CURE OF THE OPIUM HABIT AFTER TWENTY YEARS' ADDICTION.-At the last meeting of the Société Médicale de l'Elysée, Dr. Oscar Jennings showed a patient cured of the opium habit after an addiction of nearly twenty years. The gentleman in question was a member of the medical profession, and had repeatedly failed in his attempts at self-cure at the critical moment. The suppression of the drug had been effected in three weeks, and ten days had elapsed since the last dose was taken. The patient stated that he was still suffering from prostration and from intermittent pain, but he felt none of that horrible craving for opium that compelled to the use of that stimulant. The treatment was that always adopted by Dr. Jennings, the chief remedies employed being heart tonics and trinitrine in the form of the compound tabloids, galvanization of the brain; hot-water and hot-air baths had also been used, together with other occasional prescriptions.London Lancet.

CASE OF DISEASE OF THE HIP-JOINT, FOLLOWED BY DISLOCATION ON TO THE DORSUM OF THE ILIUM. OPERATION FOR REDUCTION OF THE DISLOCATION, FOLLOWED BY EXCISION OF THE HEAD OF THE FEMUR.-M. B., a girl aged twelve, from Linlithgow, was admitted to my wards on the 25th of September, 1889. The history given was that she had pulled the shafts of a cart over on her the day before. She complained of pain in the right hip and knee. She presented the appearances most typically of dislocation of the right hip on to the dorsum ilii. There were no evidences of any recent injury, but the girl was remarkably hysterical, and had evidently got a severe fright. As I was absent from town, Mr. Caird examined the girl, and came to the conclusion that the dislocation was not recent, and was probably due to disease of joint. In a few days the patient was able to get up and to walk a little, with the toes of the right foot touching the ground. It was then learned that she had received an injury, supposed to have been a fall on the knee, more than a year before, and had been lame and unable to put the whole foot to the ground ever since.

When I resumed the charge of my wards, a few days after the patient's admission, I found the girl able to go about, but very lame, and with well-marked signs of dislocation of the right hip on the dorsum ilii. The previous history being very uncertain, as obtained from the child herself, and also from the friends through the doctor in the country, I was uncertain as to whether there had been disease antecedent to the first injury. As to the dislocation being of old standing I had no doubt. With the consent of the parents I decided to cut down on the head of the femur, remove it if it was diseased-return it to the acetabulum, if possible, if it was healthy; and in either case to do my best to obtain a straight limb for my patient. Accordingly, on the 25th October, one month after the patient's admission, assisted by Mr. Caird, I cut down on the head of the femur where it lay on the dorsum of the ilium. We found no evidence whatever of recent injury. The neck of the femur was surrounded by dense muscular and fibrous adhesions. When

these were cut through, with some difficulty, we found the head of the femur apparently perfectly healthy, but without a scrap of ligamentum teres attached to it. On examining the acetabulum it was felt to be filled with what we took to be granulation tissue. It was not scraped. This, I now think, was a mistake. With a little gentle manipulation the head of the femur slipped into the acetabulum. The girl's legs were then brought together and seen to be of the same length. The wound was irrigated, and stitched up with a rubber drain

age-tube at the most dependent part, and continuous extension applied to the limb.

Most unfortunately the wound suppurated. The child did fairly well, except that a sinus remained where the drainage-tube had been placed. This sinus was found two months after the operation to lead to carious bone. The old incision was therefore opened up on 26th December, and the head of the femur removed in a carious condition. By the 27th March, 1890, the wound was quite healed, the patient wearing a Thomas' hip-splint when up. On careful measurement the right leg is found to be half an inch shorter than the left, and the trochanter half an inch higher up and slightly more anterior on the right side than on the left side. The natal fold is well marked on both sides. The right limb is almost as well nourished as the left. There is some power of movement of the right hip.

Remarks. 1. From the condition of matters found at the operation, the absence of all signs of recent injury, and the dense adhesions that existed, amounting to a new capsule for the head of the femur, I am certain that the dislocation was of old standing, and had occurred probably at the time of the first injury, more than a year before admission. This is confirmed by the statements of the parents, that the girl had walked on the toes of the right foot ever since that time.

2. From the absence of all trace of the ligamentum teres, the presence of granulation tissue in the acetabulum, and the immediate occurrence of carious disease in the head of the femur on its return to the acetabulum, I cousider that disease of the hip-joint (acetabulum) preceded dislocation and tended to make the production of this injury, which is so uncommon in children, more easy. I was prepared to find this result, for Dr. Henry Alexis Thomson had drawn my attention to the cases published by König, who says: "Dislocation in tubercular disease of the hip usually depends on osseous coxitis, especially of the acetabulum. It occurs under slight injury, and the femoral head travels in the same directions as in traumatic dislocations. A blow on the knee or the weight of the bed-clothes may be sufficient. In most of my cases the acetabulum had become partly filled up with tubercular granulations.

The ligamentum teres is always destroyed" (from notes by Dr. H. A. T). König's treatment of such cases is to excise the head of the femur, even though it may seem to be quite healthy. He has published three cases similar to mine, in two of which the head of the femur seemed to be healthy, and in all the acetabulum was diseased.—Mr. A. G. Miller, Edinburgh Medical Journal.

BACTERIOLOGY OF TYPHOID SUPPURATIONS. A large majority of authors deny any pyogenic properties of the typhoid bacillus, and ascribe the complications to a "mixed infection" of the patient's system with the specific microbe of enteric fever, and various pyogenic bacteria. Of late, however, a series of cases was reported (by Fraenkel, Kocher, Favel, Weichselbaum, Roux, Vinay, Valentini, and Ebermaier) in which a most careful bacterioscopic examination of typhoid abscess failed to reveal the presence of any microbes beyond the typhoid rods. The question naturally arising, "whether the specific typhoid microbe can give rise to suppurative inflammation or not," Dr. Orloff has undertaken a very extensive course of inoculation experiments on rabbits and dogs, which enables him to lay down the following propositions:

1. Injections of "pure cultures" of the typhoid micro-organism into tissues give rise to local inflammation, with round cellular infiltra

tion.

2. When injected into joints, the microbes cause the appearance of a sero-purulent, frequently thick, mucoid effusion.

3. When introduced under the periosteum or into muscles, the bacilli produce round cellular infiltration (chiefly in interstitial connective tissue), followed by partial sloughing, with disintegration or (more rarely) suppuration.

4.. A similar infiltration is also observed after injections of the cultures into the testicle, fractured bones, and inflamed subcutaneous cellular tissue.

5. A subcutaneous injection of the bacilli (in dogs) brings about the development of abscess.

6. The injection into a healthy pleural cavity gives negative results.

7. Injections of sterilized (dead) cultures of the typhoid rods are followed by the same morhid phenomena as described sub, though in a less intense degree.

8. The fact justifies the supposition that phlogogenic and pyogenic properties of the microbes are dependent-at least to a considerable extent upon some chemical substances (such as Brieger's typhotoxin) developing in the cultures in connection with their vital pro

cess.

9. In such cases of suppuration complicating or following enteric fever, where the pus proves to contain the typhoid bacilli alone, the morbid process (suppuration) must be attributed to the latter, and not to Brieger's "mixed infection" (vide supra).

10. In mixed cultures, the typhoid microbe does not appear to produce any influence on the vitality of the staphylococcus pyogenes aureus.-Provincial Medical Journal.

TREATMENT OF CONSUMPTION.-It is reported that Dr. W. H. Burt, of Chicago, has recently proposed hyper-alimentation and the drinking of very large quantities of water as a cure for consumption. Eight months ago, when reading of the change brought about in the obesity of Prince Bismarck through refraining from the use of water and carbo-hydrates, it occurred to Dr. Burt that an opposite treatment ought to result in the cure of all wasting diseases. He now states his belief that excessive eating and the excessive use of water will cure fifty per cent of all consumptive cases in their first and second stages. He explained at length the tonic influence and power in building up tissue possessed by water, which forms three fourths of the human body, and said that even in health six pints a day were necessary to meet the water waste, and in disease twelve pints.

At a recent meeting of the Chicago Medical Society he is said in the daily papers to have pronounced the bacteria theory, so popular of late, to be pure nonsense. The treatment he proposed consisted in the free use of water every hour in the day, nine hours' sleep regularly, and, if possible, the sea or mountain air. Above all, the patient must look upon the drinking of water as his life. Regarding heredity as the great danger, Dr. Burt advocated the passing by Congress of a law forbidding the marriage of consumptives. With this in force, one hundred years from now, he thought, consumption would not exist in the United

States.

OPERATION FOR HABITUAL DISLOCATION AT THE SHOULDER-JOINT.-At the meeting of the Berlin Medical Society, July 2, 1890, Prof. Max Schüller showed a boy, fourteen years old, on whom he had performed, four years ago, an excision of the ankle-joint for an acute suppuration of the joint after an acute osteo-myelitis of the tibia. The excision was subperiostal, according to Von Langenbeck's approved method. The shape of the new joint is now quite normal, so that it is of some difficulty at first sight to say which is the operated joint. Besides, the usefulness of the joint is so complete that the boy can run, jump, climb, and share in all sports and gymnastics as well as his fellows.

Dr. Schüller finally showed a good specimen of habitual dislocation of the shoulder-joint, which he treated by excision of the joint. The patient was a young woman who for fourteen years had had innumerable dislocations, and at last could not use the arm for pains. Schüller found on the posterior part of the head of the humerus a depression made, he believes, by the pressure of the head on the inner border of the glenoid cavity, where it lay seemingly all the

time. The glenoid cavity was eroded on its inner border, and on the lower part it was ir regularly sharpened as if it had been broken sometime before. Schüller supposes, according also to his experimental studies (Schüller's Surgical Anatomy, I, § 94), that in his case a fracture of the rim of the glenoid cavity was the first cause of the recurring dislocation. This fracture can have this effect then, if the patient, after the reposition, is allowed to use the arm before the fracture is healed. A fracture of the head and of the tubercula could not be found, and the scapular muscles were intact, as now, after healing of the excision, faradization induces rotation of the humerus.-Med. and Surg. Rep.

INFLAMMATORY LEUCOCYTOSIS.-Von Limbeck's investigations, brought forward at the Heidelberg Congress last year, have shown that the white corpuscles of the blood, physiologically increased in number during digestion, are considerably increased in number in all acute diseases which are accompanied by coagulating exudations-for example, lobar pneumonia and suppurative peritonitis. This increase does not occur in the infectious diseases which give rise to no exudations into the tissues-for example, typhoid fever, intermittent fever, septic fever-even if the temperature rises very high. The danger of this inflammatory leucocytosis is mostly proportioned to the degree of exudation and its richness in cells; it declines critically with defervescence; it does not occur with stationary exudations, and it is not diagnostically, but prognostically, a valuable criterion. In a discussion on this subject at Prague (Verein deutscher Aerzte), Von Jacksch confirmed the statements of Von Limbeck as regards typhoid and lobar pneumonia in children, the proportion of white to red corpuscles being 1:40 to 75. In the latter disease the hemoglobin amount was also distinctly lessened. (Berliner klin. Wochenschrift, No. 51, 1889).-British Medical Journal.

CAN JAUNDICE BE INFECTIOUS?-Epidemic jaundice has been attributed to a variety of causes. It has been shown to be associated with enteric and malarious fevers; to have resulted from sanitary defects, from arsenical poisoning, and from climatic influences. As to uncomplicated jaundice ever being truly contagious, there does not appear to be much evidence. But, as catarrh in other forms may be communicable, there would seem to be no reason for denying the communicability of catarrhal jaundice. The following group of cases strongly suggests its occasional infectiveness. H. E., aged nine years and a half, got a chill

A

from "paddling" in the sea last summer. laryngeal catarrh resulted, which was followed by an attack of catarrhal jaundice. Three weeks later his two sisters, aged eleven and six years, had similar attacks; while two brothers, aged seven and four, succumbed a week afterward. A younger child of three years and a half escaped. All these children's cases were well-marked instances of catarrhal jaundice, and in none of them (except the first, who paddled") was there any explanation of the illness to fall back upon except infection.-Dr. Thomas F. Raven, London Lancet.

SALOL IN THE GASTRO-INTESTINAL DERANGEMENTS OF CHILDREN.-Salol is an easily administered, safe drug in the first stage of gastro-enteritis in children, and in more chronic forms of entero-colitis, accompanied by slimy, bad smelling evacuations. In the acute condition it is necessary to keep the stomach at rest and administer two or three doses of salol within five or six hours. For the more chronic state of catarrh it is best given in somewhat larger doses before meals. In frequent serous discharges and in colitis the salol does not produce the same good results as in the case mentioned above, and its effect is uncertain, not being so rapid or so sure as an opiate.

on.

In dysenteric disorders it can not be relied It seems, then, that salol acts best in morbid conditions due to fermentation and decomposition in the stomach and upper bowel, and that it diminishes in power as it passes through the large intestine.-Walter Lester Carr, M. D., Arch. of Pediatrics.

TREATMENT OF STRANGULATED HERNIA.— My experience agrees with that of Mr Robert Marriott, in regard to the value of the ice-bag in the treatment of strangulated hernia. I first observed it in a case under the care of Mr. Marshall in the wards of University College Hospital many years ago-a case of femoral hernia, with strangulation, where all treatment was ineffective until it was applied. In several private cases since that time I have applied it with success; and in the last case of the kind, after every other means had failed, I left the ice-bag on while preparing to operate, and on returning to the patient found that reduction had taken place. I was surprised to see it condemned as useless by so high an authority as Mr. Heath, and, as it is a matter of importance, it would be interesting to know what is the experience of others. It appears to act by causing a contraction of the blood vessels, whereby the size of the tumor is diminished. In a case of long duration, with impaired vitality and contractility of the tissues, I can conceive

that it might do harm by increasing the danger of gangrene, though even here it is possible that the application of a cold approaching that of freezing suspends rather than destroys vital changes. In any case, I should say that if good does not result from the application of the ice-bag for from one to two hours (according to the size of the hernia), it is useless to continue it.-Dr. Chas. A. Rayne, London Lancet.

DIABETES IN CHILDREN. Dr. Stern, of Berlin, has collected one hundred and seventeen cases of diabetes in children, and thinks that this affection is by no means so rare in childhood as is frequently supposed. The girls in his list are more numerous than the boys, the proportion being five to three. No age would appear to be free. Six of the cases occurred in infants under a year old. The parents of the affected children were in some cases themselves diabetic, but in many more instances they were suffering from some neurotic trouble. The disease in many cases seemed to have come on after gastric catarrh, purpura, measles, or concussion of the brain. As to the prognosis, he finds that three fourths of the cases were fatal, as was every case in which the affection had lasted for a year or more. The disease did not appear to run a more rapid course in younger than in older children. Ibid.

HYDRAMNION IN TWIN PREGNANCY.-Dr. Kruse, of Greifswald, described in the Deutsche Med. Wochenschrift, No. 5, 1890, a case where this interesting condition occurred in single-arm twin pregnancy. The patient was aged fortyone, and had borne seven children. After a fall the abdomen suddenly increased in size, and dyspnea set in. When she was admitted to hospital, twin pregnancy at the sixth month, with hydramnion of one fetus, was diagnosed. An elastic catheter was introduced in order to induce labor, but without effect. The membranes were ruptured, and the twins were then rapidly expelled. Seven quarts of liquor amnii came away. The twins and membranes were carefully examined. None of the conditions alleged by some authorities to be the cause of hydramnion in single ovum twin pregnancy were present. One fetus was smaller than its brother, but there was no anemia of the one with corresponding plethora of the other. The placental circulation was perfect throughout the placenta and cords. The bladder of the bigger fetus was greatly distended with urine, the ureters tortuous, and the renal pelves dilated. This condition was attributed by Dr. Kruse to a mechanical impediment to the escape of urine. That impediment was, in his opinion,

the pressure of the amniotic fluid, for there was no obstruction of any kind in the genitourinary tract itself. The hydramnion was thus not caused by polyuria in the fetus. The smaller size of one fetus Dr. Kruse attributed to the fact that it received blood from a less extensive surface of placenta than in the case of its brother. In short, the cause of the hydramnion could not be determined. British Medical Journal.

THE DIAGNOSTIC AND PROGNOSTIC VALUE OF UROBILINURIA.-Hayem (Gaz. Hebd., xxxvi) claims the same diagnostic value for urinalysis in diseases of the liver as in diseases of the kidney. While in the latter case we are on the look-out for albuminuric acid, etc., in the other the coloring matters are the ones to be considered. As no urobilin is found in the urine of healthy animals, Hayem concludes that urobilinuria always means a disturbance of the liver. That the condition is so frequently found is due to improper diet and the use of alcohol. The degree of urobilinuria is an index of the gravity of the liver changes. While with light drinkers the quantity of urobilin is small and may completely disappear from the urine, in those of persistent free urobilinuria, with a history of alcoholic excesses, we certainly have to do with a cirrhotic liver. The importance of this symptom is apparent when we think that it occurs early, long before other signs appear.

INFLAMMATION OF COWPER'S DUCT.-This disease of the vulva is of considerable importance. It is a painful affection, and its causation is not absolutely established. Dr. Matthews Duncan holds that abscess of Cowper's gland and cystic dilatation of its duct are welldefined diseases; suppuration of the duct and cystic degeneration of the gland being, on the other hand, quite rare. Dr. Pollacsek, of BudaPesth, has published some researches on the subject, which will be found in the Centralblatt für Gynäkologie, No. 22, 1890. He believes that inflammation of the gland is, as a rule, thd result of injury, and is not of gonorrheal origin, excepting when the duct is involved or when the duct alone is inflamed. Dr. Pollacsek distinguishes four varieties of "Bartholinitis." The first is simple catarrh of the duct; suppuration may occur, but the inflammation is not specific, and no gonococci are to be found. In gonorrheal catarrh of the duct, the second variety, the gland is rarely involved, and in exceptional cases but slightly swollen. Suppuration is rare, but this variety

frequent in prostitutes-is very chronic and intractable. The third variety is idiopathic