ing to the extent of the action of the remedy. To recapitulate, the remedy does not kill the tubercle bacilli, but the tuberculous tissue, and this gives us clearly and definitely the limit that bounds the action of the remedy.

It can influence living tuberculous tissue only, and has no effect on dead tissue; as, for instance, necrotic cheesy masses, necrotic bones, etc., nor has it any effect on tissues made necrotic by the remedy itself. In such masses of dead tissue living tubercle bacilli may possibly still be present and are either thrown off with the necrosed tissue, or may possibly enter the neighboring and still living tissue under certain circumstances of the therapeutic activity. If the remedy is to be rendered as fruitful as possible, this peculiarity in its mode of action must be carefully observed. At first the living tuberculous tissue must be caused to undergo necrosis, and then every thing must be done to remove the dead tissue as soon as possible, as, for instance, by surgical interference.

Where this is not possible, and where the organism is unassisted in throwing off the tissue slowly, the endangered living tissue must be protected from fresh incursions of the parasites by continuous applications of the remedy. The fact that the remedy makes tuberculous tissue necrotic, and acts only on the living tissue, helps to explain another characteristic thereof, namely, that it can be given in rapidly-increasing doses. At first sight this phenomenon would seem to point to the establishment of tolerance; but since it is found that the dose can, in the course of about three weeks, be increased to five hundred times the original amount, tolerance can no longer be accepted as an explanation. As we know of nothing analogous to such a rapid and complete adaptation to an extremely active remedy, the phenomenon must rather be explained in this way, that in the beginning of the treatment there is a good deal of tuberculous living tissue, and that consequently a small amount of the active principle suffices to cause a strong reaction, but by each injection a certain amount of the tissues capable of reacting disappears, and then larger doses are necessary to produce the same amount of reaction as before.

Within limits, a certain degree of habitu

ation may be perceived as soon as the tuberculous patient has been treated with increasing doses; for so soon as the point is reached at which reaction is as feeble as that of a non-tuberculous patient, then it may be assumed that all tuberculous tissue is destroyed. Then the treatment will only have to be continued by slowly increasing doses and with interruptions, in order that the patient may be protected from fresh infections while bacilli are still present in the organism; and whether this conception and the inference that follows from it be correct, the future must show. They were conclusive, as far as I am concerned, in determining the mode of treatment by the remedy, which in our investigations was practiced in the following manner. To begin with the simplest case, lupus.

In nearly every one of these cases I injected the full dose of 0.01 cubic centimeter from the first. I then allowed the reaction to come to an end, and then, after a week or two, again injected 0.01 cubic centimeter, continuing in the same way until the reaction became weaker and weaker and then ceased. In two cases of facial lupus the lupus spots were thus brought to complete cicatrization by three or four injections; the other lupus cases improved in proportion to the duration of treatment.

All these patients had been sufferers for many years, having been previously treated unsuccessfully by various therapeutic methods. Glandular, bone, and joint tuberculosis was similarly treated, large doses at long intervals being made use of. The result was the same as in the lupus cases, namely, a speedy cure in recent and slight cases, slow improvement in

severe cases.

The circumstances were somewhat different in phthisical patients, who constituted the largest number of our patients. Patients with decided pulmonary tuberculosis are much more sensitive to the remedy than those with surgical tuberculous affections.

We were obliged to diminish the dose for the phthisical patients, and found that they almost all reacted strongly to 0.002 cubic centimeter, and even to 0.001 cubic centimeter. From this first small dose it was possible to rise more or less quickly to the amount that is well borne

by other patients. Our course was generally as follows: An injection of 0.001 cubic centimeter was first given to the phthisical patient, and from this a rise of temperature followed, the same dose being repeated once a day until no reaction could be observed. We then increased the dose to 0.002 cubic centimeter, until this was borne without reaction, and so on, increasing by 0.001, or at most 0.002 to 0.005 cubic centimeter.

This mild course seemed to be imperative in cases in which there was great debility. By this mode of treatment the patient can be brought to tolerate large doses of the remedy with scarcely a rise of temperature. But patients of greater strength were treated from the first partly with larger doses and partly with frequently repeated doses. Here it seemed that the beneficial results were more quickly obtained. The action of the remedy in cases of phthisis generally showed itself as follows: Cough and expectoration were generally in creased a little after the first injection, then grew less and less, and in the most favorable cases entirely disappeared. The expectoration also lost its purulent character and became mucous. As a rule, the number of bacilli decreased only when the expectoration began to present a mucous appearance. They then entirely disappeared, but were again observed occasionally until expectoration completely ceased. Simultaneously the night-sweats ceased, the patients' appearance improved, and they increased in weight within from four to six weeks.

Patients under treatment for the first stage of phthisis were freed from every symptom of disease and might be pronounced cured; patients with cavities not yet too highly developed improved considerably and were almost cured, and only in those whose lungs contained many large cavities could no improvement be proved. Objectively, even in these cases the expectoration decreased and the subjective condition improved. These experiences lead me to suppose that phthisis in the beginning can be cured with certainty by this remedy. This statement requires limitation, in so far as at present no conclusive experiences can be possibly brought forward to prove whether the cure is lasting.

Relapses naturally may occur, but it can be assumed that they can be cured as easily and quickly as the first attack. On the other hand, it seems possible that, as in other infectious diseases, patients once cured may retain their immunity; but this, too, for the present, must remain an open question. In part, this may be assumed for other cases, when not too far advanced; but patients with large cavities, who suffer from complications caused, for instance, by the incursion of other pus-forming microorganisms into the cavities or by incurable pathological changes in other organs, will probably obtain lasting benefit from the remedy in only exceptional cases. Even such patients, however, were benefited for a time. This seems to prove that in their cases, too, the original tuberculous disease is influenced by the remedy in the same manner as in the other cases, but that we are unable to remove the necrotic masses of tissue with the secondary suppurative processes.

The thought involuntarily suggests itself that the relief might possibly be brought to many of these severely afflicted patients by a combination of this new therapeutic method with surgical operations (such as the operation for empyema), or with other curative methods; and here I would earnestly warn people against conventional and indiscriminate application of the remedy in all cases of tuberculosis. The treatment will probably be quite simple in cases in which the beginning of phthisis and simple surgical cases are concerned, but in all other forms of tuberculosis medical art must have full sway by careful individualization and making use of all other auxiliary methods to assist the action of the remedy.

In many cases the decided impression was created that the careful nursing bestowed on the patient had a considerable influence on the result of the treatment, and I am in favor of applying the remedy in proper sanataria as opposed to treatment at home and in the out-patient room. How far the methods of treatment already recognized as curative, such as mountain climate, fresh air treatment, special diet, etc., may be profitably combined with the new treatment can not yet be definitely stated; but I believe that these therapeutic methods will

also be highly advantageous when combined with the new treatment. In many cases, espeIn many cases, especially in the convalescent stage, as regards tuberculosis of the brain and larynx, and miliary tuberculosis, we had too little material at our disposal to gain proper experience.

The most important point to be observed in the new treatment is its early application. The proper subjects for treatment are patients in the initial stage of phthisis, for in them the curative action can be most fully shown, and for this reason, too, it can not be too seriously pointed out that practitioners must in the future be more than ever alive to the importance of diagnosing phthisis in as early a stage as pos. sible. Up to the present time the proof of tubercle bacilli in the sputum was considered more as an interesting point of secondary importance, which, though it made diagnosis more certain, could not help the patient in any way, and which in consequence was often neglected.

This I have lately repeatedly had occasion to observe in numerous cases of phthisis which had generally gone through the hands of several doctors without examination of the sputum having been made. In the future this must be changed. A doctor who shall fail to diagnose phthisis in its earliest stage by all methods at his command, especially by examining the sputum, will be guilty of the most serious neglect of his patient, whose life may depend upon the early application of the specific treatment. In consequence, in doubtful cases medical pactitioners must make sure of the presence or absence of tuberculosis, and then only will the new therapeutic method become a blessing to suffering humanity, when all cases of tuberculosis are treated in their earliest stage, and we no longer meet with neglected serious cases forming an inextinguishable source of fresh infections. Finally, I would remark that I have purposely omitted statistical accounts and descriptions of individual cases, because the medical men who furnished us with patients for our investigations have themselves decided to publish the description of their cases, and I wished my account to be as objective as possible, leaving to them all that is purely personal.-Philadelphia Medical News.

A NEW TEST FOR ALBUMEN IN URINE.— The following tests have been published by Zouchlos (Rundschau, 1890), and are recommended on account of their simplicity and accuracy: A solution of one part of acetic acid and and six parts of one-per-cent solution of corrosive sublimate is prepared; to this the suspected urine is slowly added, which at once produces a distinct cloudiness. This test is not affected by peptones, uric acids, or the phosphates. A still more delicate test than the above has been proposed by Zouchlos: Three ounces of a tenper-cent solution of rhodium potash, with six drams of acetic acid; of this a few drops are added to the suspected urine. If albumen is present, there is at once formed a distinct cloudiness, which is insoluble in excess of the solution.-Virginia Medical Monthly.

THEINE IN THE TREATMENT OF NEURALGIA. Every now and then cases of neuralgia are reported which have been treated successfully by the hypodermic injection of theine. The local anesthetic action of this alkaloid was, we believe, first brought to the attention of the profession by Dr. Thomas J. Mays, about four years ago, who, from his experimental and clinical investigation, concluded that its physiological action is not identical with that of caffeine, and that its analgesic action is more prompt and more permanent in neuralgia than that of morphine or of any of the other agents in common use for the purpose of deadening pain. Med. and Surg. Rep.

FLUOROFORM.-The Monthly Journal of Pharmacy states that a French chemist, M. Meslans, has succeeded in preparing fluoroform. It is the analogue of chloroform and iodoform, the chlorine and iodine of these substances being replaced by fluorine in fluoroform. But whereas chloroform is a liquid and iodoform is a solid at ordinary temperatures, fluoroform is a gas. It is colorless, and has a pleasant ethereal smell, recalling that of chloroform.

DR. C. HANFIELD JONES, of London, died at his residence, on September 30th, aged seventy-two years. He was best known by his work on "Functional and Nervous Diseases."

VOL. X. [NEW SERIES.]

Certainly it is excellent discipline for an author to feel that he must say all he has to say in the fewest possible words, or his reader is sure to skip them; and in the plainest possible words, or his reader will certainly misunderstand them. Generally, also, a downright fact may be told in a plain way; and we want downright facts at present more than any thing else.-RUSKIN.

Original Articles.

THREE LAPAROTOMIES OF MORE THAN ORDINARY INTEREST.

BY DOUGLAS MORTON, A.M., M.D. Consulting Gynecologist to the Louisville City Hospital.

Mrs.

CASE 1. Obstruction and Inflammation of the Gall Bladder; Aspiration and Subsequent Abdominal Section; Recovery. The interest connected with the first of these cases lies not at all in the abdominal section itself, but in the pathological conditions found on opening the peritoneum, and in the result of other measures carried out in the treatment of the case. M., a feeble person of cachectic aspect, aged thirty, came to me giving a history of repeated attacks of biliary colic during the past four years, and of almost constant bad health all that time. Her chief trouble was pain in the right hypochondrium, in which region I found a tumor that projected below the costal border, reaching an inch lower than the umbilicus and to within two inches of the median line, and measured about four inches across and five vertically. As doubt as to the nature of the tumor had been expressed by several prominent physicians under whose charge she had been at different times, and the patient was not willing at this time to submit to exploratory incision, I used the aspirator to aid in diagnosis, and obtained a clear, yellowish, viscid fluid that contained cholesterin crystals and a small quantity of pus. This, taken with other evidence, I thought conclusive enough.

The aspiration caused some reaction, and the

No. 12.

tumor became more distended and painful than before. Ten days later I aspirated again, this time drawing off over two ounces of a fluid in which the quantity of pus had evidently increased very much. On this occasion I injected through the needle an ounce of a weak solution of compound tincture of iodine as an antiseptic. This was speedily followed by still more reaction, and in a few days distension became so great and painful that aspiration, simply for immediate relief, became urgent.

In the meantime I had become disgusted with the procedure, and the patient was willing to submit to the knife. Accordingly a few days afterward, aided by Drs. Cartledge and Bullock, I set about doing the operation of cholecystotomy, but just as I reached the peritoneum the patient fell into an alarming condition from chloroform poisoning, making it necessary to suspend our work and resort to means of resuscitation. In time she rallied, and the operation was continued by opening the peritoneum. It was now found that the whole tumor was covered by the hypertrophied right lobe of the liver, the thin border of which extended to an inch below the level of the umbilicus. Under this, by passing the fingers through the lower part of the wound, the distended gall-bladder could be easily felt. At this juncture the patient was beginning again to do badly under the anesthetic, and as it had been found that to complete the operation would involve considerably prolonged work it was deemed best to leave it incomplete.

The wound healed in a few days by first intention, and much to our surprise the tumor gradually diminished in size until at the end of three months it became inappreciable.

As enlargement of the liver is common in cholecystitis-indeed, perhaps always present in cases of long standing-the condition found

in this case of a cyst entirely overlapped by the liver is likely not at all rare, though I have the record of only one case, reported by Dr. Shepherd, of Montreal, at a late meeting of the Canadian Medical Society. The presence of this condition would obviously greatly increase the difficulty of either the usual operation of cholecystotomy in which a biliary fistula is established, or of cholecystectomy.

The operation apparently most feasible in such a case would be a cholecystotomy in which the incision through the cy-t wall is closed by sutures and the viscus dropped back. In order, however, to do the necessary manipulation, a more than usually long parietal incision would be required.

The ultimate healing of the cholecystitis may have been due to dislodgment of the obstructing calculus caused by the great distension of the cyst that followed the iodine injection, and to the arrest of suppuration by the injected iodine.

CASE 2. Laparo-colotomy for Rectal Stricture and Ulceration; Recovery; Condition two years after; Present Status of Colotomy. A report of this case was publi-hed in the American Practitioner and News two years ago, and at that time I thought the case could be justly considered one of e-pecial interest, as being the first successful colotomy that had been done in this city. My apology for presenting this case again is, that I can describe the condition of the patient two years after the operation, and that as I quoted in my first account the denunciatory language used by leading authors against the operation not many years before, I can now quote recent expressions from leading authors of the present day showing a most complete change of opinion. This latter I am all the more willing to do, as I believe there still prevails in this city a prejudice against the operation.

The patient, a woman aged thirty, had been suffering from a broad, tight stricture, complicated with extensive ulceration and a rectovaginal fistula. At the time of the operation she was in a deplorable condition, and by all rules a proper subject for colotomy. The operation was essentially that of Cripps; the result, speedy recovery with immense improve

ment of condition. Now after two years her general health is fully restored, and she has been able to earn her living as cook and laundress. She was at the hospital a short time during the past summer for diarrhea and abrasion of the mucous membrane prolapsed through the artificial anus. At this time the resident physician who saw her last tells me the circle of protruded mucous membrane was about two inches in diameter, and projected somewhat more than half an inch.

Except when she has diarrhea, this patient is not greatly annoyed with involuntary fecal discharge, and, although she can not control it, she has some premonition of its approach. The fear of becoming offensive to others would naturally deter a sensitive person from undergoing colotomy. This is certainly, in the main, unfounded.

As to the present status of the operation, I will quote from a late paper by Mr. Bryant, consulting surgeon of Guy's Hospital. He says it "is still too much regarded as a dernier res sort. . . . This position of colotomy I, in common with a few other surgeons, have, however, never accepted. We have regarded it as the best means the surgeon has at his disposal for the relief of rectal obstruction from cancerous and other disease which is not otherwise removable. . . . Within the last ten years there has consequently been a remarkable advance in the position of colotomy." Dr. Kelsey, of New York, said recently: "As to the benefits arising from the operation, scarcely too much can be said. . . . I can only say after trying every other means of treatment, and being obliged to admit the fruitlessness of them all, I have come with most others to admit the great benefits of colotomy, and have never performed it in any case in which either the patient or myself have regretted it. . . . There can be no argument in favor of colotomy so strong as a single experience with a case of cancer of the rectum left to its own course and termination in fatal obstruction."

I consider the operation the easiest in abdominal surgery, and the safest also if not put off too long.

CASE 3. Removal of Sarcomatous Ovarian Tumor; Pedicle Treated by Unusual Method; Recov