sible, I have no doubt, to obtain the same result in the case of other diseases. This opens up an oft-promised field of work, with problems which are worthy to be the subject of an international competition of the noblest kind. To give even now some encouragement to further researches in this direction was the sole and only reason why I, departing from my usual custom, have made a communication on a research which is not yet completed.

Allow me, therefore, to conclude this address with the expression of a wish that the nations may measure their strength on this field of labor and in war against the smallest but the most deadly foes of the human race, and that in this struggle for the weal of all mankind one nation may always strive to surpass the other in the successes which it achieves.

BLEEDING.—in an interesting inaugural address on the impressions remaining after a general practice of thirty-seven years, Dr. Alfred Freer, in the Birmingham Medical Review,

says:

every

There is one old remedy that has, like disease, slain its thousands in divers countries, which I long, nevertheless, to see set up again upon a proper pedestal among the worthies, that is, bleeding. True it is this power was much abused in old days, but we all must have met with cases where the non-exercise of this potent spell has filled us with regret. I am old enough to remember the time when at least week patients brought rolls of tape which they would pull out of their pocket, saying, with at somewhat dissatisfied tone, "Then you are not going to bleed me, sir?" Phlebotomy has so gone out that is only with bated breath one dare hint at the propriety of its performance. And yet there are many cases which I think might be saved by it. Let me take three or four examples. Years ago I was summoned most urgently to a young butcher supposed to be dying, his own medical attendant being away from home. I found a man not able to lie down, gasping for breath, and suffering from a pleurisy of three days' duration. He begged me to do something, and it was plain that unless speedily relieved he must die. I bled him to sixteen ounces, and it was a treat to see the

poor fellow expand his chest freely and enjoy the relief of the blood flow. From that moment all anxiety was over. Take another, a chronic case, not in my practice, but the circumstances well known to me. A well-to-do man of about sixty, suffering from cardiac valvular mischief, pulmonary congestion, and great edema of legs, ready to die. A practitioner of before 1815. and most unduly devoted to the practice of opening veins, was called in, superseding the regular attendant. He bled the patient with striking benefit. After the operation the much needed diuretics acted like magic. Elated by success, Sangrado repeated the venesection with still more marked relief. A third and fourth, repetition, and the patient sank into such a profound anemia that he could not rally. The abuse of the remedy spoiled all. A third example: A year ago I was called to a woman aged fifty-three, generally soddened in beer, who was seized with giddiness, inability to speak to be understood, pain in the head, and incomplete left hemiplegia, while walking. Her speech was always mumbling at best. I bled her to twelve ounces with immediate benefit; and the friends exclaimed, on hearing her talk, "Why, we have not heard her speak so plainly for three four years." With the exception of diminished power in the left arm this woman has practically recovered, and I often meet her going to refresh.

Yet another example in which bleeding gives excellent results. I allude to puerperal eclampsia. What anxiety comes to especially young and isolated practitioners from seizures of this nature? I remember a primipara, white-faced and unmarried, who had violent convulsions in the first stage of labor; my father had bled her freely with much temporary abatement of the fits. In four hours they returned with violence, and on my father's advice I bled again to sixteen ounces, and gave one grain of tartar emetic with one of opium. The convulsions. ceased, the confinement proceeding favorably, and the convalescence was uninterrupted. I do not mean it to be inferred that under modern superior light I would adopt such heroic treatment now, but I venture to aver that in many cases of puerperal eclampsia, where the renal secretion is scanty and decidedly albu

minous, and where there is marked edema of the lower limbs, the withdrawal of some blood from the circulation is a most valuable resource.

Severe epistaxis often gives us a strong hint on this matter, and so does that severer monitor, hematemesis. Many a possessor of a chronically congested liver has been put on his legs again for an indefinite period through having passed through a hematemesis so profuse as to bring him for a time to death's door. We must not forget that the benefit of venesection or the abstraction of blood does not end with itself, but gives opportunity for the introduction of other valuable remedies into the lightened circulation.

THE GRIPPE CONSIDERED FROM A SURGICAL STANDPOINT.—The recent epidemic of la grippe has called into requisition the services of the physician rather than of the surgeon, but ant article by Prof. Verneuil, published recently in the Bulletin de l'Académie de Médicine, shows that the disease presents many points of surgical interest. M. Verneuil points out that in most of the surgical affections caused by the grippe the main pathological feature is suppuration. Thus he observed suppurative inflamation of the eye, ear, joints, purulent pleurisy, and pericarditis, the formation of superficial or deep abscesses of the skin and glands, and collections of pus in the antrum of Highmore and frontal sinus. These conditions were treated by appropriate surgical measures, but it was found that the prognosis was less favorable than under ordinary circumstances. This is not surprising, since the grippe, like other acute infectious diseases, causes marked depreciation of the patient's general health, and therefore adds materially to the dangers of any surgical operation that may have to be undertaken. Aside from this it was observed that when patients who were in the stage of recovery from an operation were attacked by the disease, the complication gave rise sometimes to serious consequences. M. Vernueil therefore lays down the rule that, excepting the conditions above mentioned, where urgent surgical interference may be indicated, it is better to postpone all surgical measures until the patient has recovered from the grippe. Owing to the slow and tedious convales

cence which characterized the disease, it may not be possible to delay the operation until recovery is assured, and in this case the best that can be done is to improve the patient's general condition as much as possible by appropriate medication.

According to the observations of Drs. Berger and Peyrat, surgical diseases ran the same course during the prevalence of the grippe as · under ordinary circumstances. On the other hand, Dr. Walther, of the Hospital de la Charité, states that patients who developed the grippe shortly after operations in which the wound was not immediately closed, as in the treatment of cold abscesses, exhibited a remarkable slowness of the healing process. Cicatrization was arrested to a certain extent, and was not re-established until several days after the complete cessation of the acute febrile symptoms. In the case of wounds sutured without drainage, healing was not interfered with, but usually two or three days after operation a sudden rise of temperature was observed. The cause of this fever could not be demonstrated, since on removal of the dressings the wound appeared perfectly healthy,

Dr. Demons, of Bordeaux, mentions quite a number of surgical complications of the grippe which have come under his observation. Otitis, complicated by suppuration in the middle ear or mastoid cells, was met with in several instances. Severe inflammation of the eye occurred in some cases, while in still others an orchitis was suddenly developed without a previous history of gonorrhea or contusion of the testicle. Fortunately, however, this disappeared as rapidly as it had appeared without going on to suppuration. There was also a formation of abscesses in the axilla, in the iliac region, and upon the leg, although none of the ordinary causes of suppuration could be found to exist. M. Demons states that all wounds in the wards of the hospital were slow in healing and in many instances suppurated profusely. In his opinion, during an epidemic of the grippe it is necessary to abstain from all operative procedures, but especially those involving the buccal, nasal, pharyngeal, and respiratory tracts, which are especially apt to be attacked by the disease.

Judging from these observations, the prognosis of the operations performed during the grippe is worthy of careful consideration, and, if possible, all surgical measures should be postponed until the patient has recovered from the debiliating effects of the disease.-International Journal of Surgery.

NOTICE.-An Army Medical Board will be in session in New York City, N. Y., during October, 1890, for the examination of candidates for appointment in the Medical Corps of the United States Army to fill existing vacan

cies.

Persons desiring to present themselves for examination by the board will make application to the Secretary of War, before October 1, 1890, for the necessary invitation, stating the date and place of birth, the place and State of permanent residence, the fact of American citizenship, the name of the medical college from whence they were graduated, and a record of service in hospital, if any, from the authorities thereof. The application should be accompanied by certificates based on personal knowledge, from at least two physicians of repute, as to professional standing, character, and moral habits. The candidate must be between twenty-one and twenty-eight years of age, and a graduate from a regular medical college, as evidence of which, his diploma must be submitted to the board. Further information regarding the examinations may be obtained by addressing the Surgeon General, U. S. Army, Washington, D. C.

J. H. BAXTER, Surgeon General, U. S. Army.

them into the surrounding connective tissue. By this means the bundles of connective tissue were separated; at last there appeared a periglandular small-celled infiltration. The microorganisms consisted of three different kinds and possessed great vitality, but soon lost their pathological strength.

Stirling, in his case of plastic bronchitis, found the casts, which were expelled in great numbers, to be white and but a few stained

Etiology. Grant' furnished a case illustrating the relation existing between gout and bronchitis. On several occasions he had been called to see a man suffering from tenderness in the epigastric region, nausea, marked flatulence with eructations, severe dyspnea and the physical signs of acute bronchitis. The urine was loaded with urates and great prostration was present. A typical gouty inflammation of the great toe supervened, and simultaneously his other symptoms subsided.

Wert found plastic bronchitis to occur frequently after pneumonia, and in many cases to be associated with grave skin affections. There seemed in one case also to be a relation between the formation of casts and the catamenia.

Pathology. Picchini describes the process in two cases of bronchitis fibrino-hemorrhagica which came under his observation. First, a hemorrhage took place in the lumen of the bronchus and a coagulum formed. Around this a little hemorrhage occurred. The epithelium of the mucosa disappeared and a small celled infiltration of the bronchial walls appeared, the mucous subcutaneous vessels enlarged, and a hemorrhagic extravasation exuded from

1 Grant, Brit. Med. Journal; Gaillard's Med. Journal, May, 1890. Practitioner, August, 1889; Medical Record, November 1889. Picchini, Riv. clin. arch. Ital. di chir. med. I, p. 103, 1889; Schmidt's Jahrb., October, 1889.

9,

three to four inches, some as much as six inches in length. As in other cases, most of these come from the small and medium sized bronchi, but in some instances the main branches represent tubes of large size, as it is not at all infrequent to find a diameter of almost half an inch, and fragments even thicker have occurred. They divide dichotomously, and are of such firm consistency as to bear frequent handling with little injury. The majority are solid, some are hollow. They have evidently been deposited in successive layers, and consist of concentric lamina which can be separated when dry. From this formation it is reasoned by this author that a considerable amount of the exudation takes place in the larger bronchi and is drawn into the smaller by efforts of inspiration. As regards chemical composition, they consist of coagulated albumen soluble in alkalies. Under the microscope they showed fibrillar material, in the meshes of which are numerous leucocytes and fat globules, some hemocytes and epithelial cells. Octahedral crystals, said to be similar to those found in bronchitic asthma, have been observed by others, but he had not been able to find the spirals seen by Curschmann.

Causade reports one of the most remarkable cases of pseudo-membranous bronchitis in med

4 Practitioner, June, 1889.

Caussade, Bull. Soc. Anat., May 10, 1889.

ical literature. He found, with the aid of chemistry, a special nature of the fibrinous blocks which has hitherto been undescribed, viz., that the syntonine enters into the fibrinous blocks. Histology revealed a structure in these blocks of membrane analogous to the coagulations of aneurisms.

Eklund reports a case of bronchitis fibrinosa, in which the patient first had hemoptysis, then a heavy sensation in the chest and later succeeded in expectorating some casts with blood. These casts were of a grayish color, were somewhat cylindrical in shape, and had ramifications of varying length from nine to fourteen centimeters. The largest tube was as thick as a goose quill, and it continued in ramifications threadlike in thickness, some ending in loops. No other physical signs of affections of the lungs, pharynx or larynx were present. There was no more cough, pain in the chest, or dyspnea. Ordered opium and acetate of lead. He observed some blood in the expectorations later, but the coughing was insignificant and the patient continued her work. The pharynx was covered with yellow, thick, purulent masses and a dry mucus.

2

impaired at bases, elsewhere it lacks fullness; breath sounds practically inaudible over front and back; intense hollow blowing over the vertebrae above the level of the scapular spine. In the lower third of the left lung, front and back, friction-like sounds at the end of inspiration, which posteriorly were broken up; these resembled very thick creaking râles. On the right lower third in front some rumbling was audible with inspiration. The cardiac impulse was weak, but definite in the fifth left intercostal space, a little within the nipple line. Heart sounds slightly dull; precordial dullness ordinary.

Treatment. Simon recommends the careful surveillance of the secretions of urine in the management of capillary bronchitis in infants. Urinary suppression may be the principal cause of the dyspnea. If this occurs, he gives digitalis not in syrup or tincture, but 15 centigrams (about 3 grains) of the powered leaves in infusion three times in twenty-four hours.

13

Symptomology. West found plastic bronchitis characterized by the occurrence of oxysms of cough and dyspnea, which immediately ceased on expectoration of the casts. The paroxysms are usually preceded and followed by a sort of catarrh. Hemoptysis may be absent or it may be very serious. It usually at once ceases with the ejection of the casts. As a general thing but little pain is present, except that caused by coughing. In acute cases the temperature may arise to 104° F.; in chronic cases it is seldom above normal. times the onset of an attack is marked by one or more rigors suggestive of pneumonia. As a rule, each attack consists of a number of short paroxysms. It may subside after a few days never to recur again, or may last continuously for ten, fifteen, or twenty years.

Some

Stirling gives an accurate description of the physical signs found in a case of chronic plastic bronchitis: Chest symmetrical; expansion movements exceedingly slight laterally; anteriorly and posteriorly, normal; percussion note

Eklund, Tr. Med. Ass. Univ. Upsas, vol. 24, 1888.

ology and treatment to be as yet unexplored territory.

Stirling in plastic bronchitis commends inhalations of alkalies, especially aqua calcis, alone or with equal parts of water, or with 2 to 5 per cent of carbonate or bicarbonate of sodium in which the casts are soluble. An emulsion of turpentine, copaiba, and oleoresin of cubebs, and inhalants to increase the plasticity of membrane. Removal to a warm, soothing climate would probably be more useful than drugs.

Simon' advises stimulants in children, as champagne, egg- nog, or toddies. He finds quinine most valuable during the entire course of the disease. It is usually administered in from to 5 gr. doses, and is best given as a potion in glycerine with the addition of a little grape syrup. The child is well wrapped in bed and large sinapisms placed to the chest.

13 Kisch. Rev. Gen. de Clinet de Therap., July 4, 1889. Simon, L'Abielle Medical, June 3, 1889; Med. News, June 20, 1889; L'Union Med. du Canada, August, 1889; Jour. de Med. de Paris, March 10, 1889; Concours Medical.