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Disappearance of Recurrent Mammary Cancer after Oophorectomy and Treatment with Thyroid Extract.-DR. G. E. HERMAN reported in the Lancet of January 11, 1899, the case of a woman treated as above. Patient is now in good health and has gained five pound in weight. He reports* another case as follows: During the year 1895, patient was twice operated on for removal of carcinomata of the right breast. On June 11, 1898, patient was admitted to the London Hospital, with a large tumor of the left breast, and with an ulcerating surface, marking site of previous cancers. On July 12, both ovaries were removed, and later the patient was put on thyroid extract, gr. v. t. i. d., which she has since taken. She is at present in good health and has gained weight since the operation. There are some keloid-like nodules in the scar, but these have not grown and show no tendency to break down. There is some question as to the relative merit of the two steps in the treatment, but probably both are necessary. The patient will be instructed to continue the thyroid extract for the rest of her life.

On the Localization of Intracranial Tumors.— BYROM BRAMWELL† discusses the localization of cere

bral tumors from the results of observations on forty cases with autopsies, and two cases in which operation was performed, in one of which the tumor was localized and the other not. In six cases the tumor

was confined to the frontal lobe; in five others the frontal was involved in addition to other parts. The point of interest in tumors of this situation is the impairment of the mental strength of the individual. In seven cases there were well-marked mental symptoms present; in four there were no definite mental symptoms. From this the author concludes that tumors localized in the frontal lobes are more apt to be attended with well-marked mental symptoms (mental enfeeblement, loss of memory, loss of the power of attention, change in character, etc.) than tumors localized in any other part of the cerebral hemispheres. Tumors localized on the posterior surface of the temporal lobe, by irritation of the adjacent motor area, produce Jacksonian epilepsy. In one case of tumor involving the left second frontal convolution (Exner's writing speech center) there was present no agraphia. Vomiting is less frequent and less severe than in tumors situated further back. In two cases of temporo-sphenoidal-lobe tumors there were no localizing symptoms whatever. This is aptly called the silent area of the brain. In tumors of the occipital lobe there is almost constantly found involvement of vision, hemianopsia and soul blindness. seven cases the cerebellum alone was involved; in three other cases other parts were also affected. The dif

*Lancet, April 22, 1899. +Brain, No. 85, vol. 22.

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ficulty of localizing a tumor in the cerebellum is well shown by the fact that in one case, in which there were found four tumors in the cerebellum, there were absolutely no localizing symptoms present. Two cases in which distended ventricles simulated cerebral or cerebellar tumors are described. Some of the conclusions which the author draws from his extensive experience and his careful study of the cases post-mortem are the following. Great care should be taken not to put too much weight upon the clinical symptoms, in regard to the localization of a tumor. Pseudo-localizing symptoms should be distinguished from true ones. Localizing symptoms are most certainly and obviously produced in those cases of intra-cranial tumors in which the tumor is situated at the base of the brain, and in which the cranial nerves at their point of origin from the nervous tissue are directly involved by the growth. Tumors are placed in the order of their difficulty of localization as follows: Pons Varolii and medulla, centrum ovale (internal capsule), occipital lobe, motor area, cerebellum, frontal lobe, parietal lobe, temporo-sphenoidal lobe.

The Aqueous Extract of the Tubercle Bacillus and Its Derivatives.-E. MARIAGLIANO* describes a

watery extract of the tubercle bacillus, obtained in this way: Fully-developed and growing cultures are fil. tered. The bacilli remaining on the filters are collected and put into distilled water and heated for forty-eight hours on a water-bath at a temperature of 90° to 95°; the evaporated water is replaced by fresh water so that the volume remains the same. This is an aqueous tuberculin and has the same effect upon men and animals as the glycerine extract. Mariagliano believes that for experimental purposes, at any rate, the aqueous extract is superior to the other by reason of the following observations: The glycerine tuberculin often causes inflammation around the point of injection; none result from the watery extract. In experiments upon animals with the glycerine product, the glycerine itself may be a toxic product and so obscure the accuracy of the results. With the aqueous tuberculin there is found no such objection. An aqueous solution, however, loses its toxic effect comparatively quickly, in eight to ten days, and for this reason a very small amount of glycerine should be added-0.05 gram per c. c. It was found also that the water would extract more of the toxic principle from the bacteria than the glycerine, the proportion being 120 poisonous units for the water as against 80 for the glycerine. The following observations are noted concerning the derivatives of the aqueous extract: There are two substances of different degrees of solubility in aqueous tuberculin. The one group is poisonous and The soluble in water in proportion of 40 per cent. other is not toxic and is soluble to a very slight de

*Berl. klin. Wochenschr., May 1, 1899.

gree in water. Treated with alcohol the dried filtrate of aqueous tuberculin forms a greyish-white powder, slightly soluble in water and toxic. With sulphuric With sulphuric acid, white, soluble crystals are formed. An alcoholic extract of the dried filtrate forms the most toxic product of the various derivatives of the aqueous tuberculin. Mariagliano concludes that his extract is identical with the Koch T. R., but extracted at a higher temperature. Behring's tuberculin is a maceration of tubercle bacilli at a temperature of 150°.

Operation Without Anesthesia.-DR. M. D. MAKUNA reports* an operation without an anesthetic. Patient had been in an explosion, and had had his left hand and lower third of the forearm shattered, with injuries about the face and neck, and a penetrating wound of the cornea. When seen several hours later, he had lost much blood, was suffering great pain and was violently convulsed. Pulse was feeble and intermittent; heart action was spasmodic. He was given some milk and brandy, and an injection was made of morphia sulp. gr., atropine gr. To, and digitalin gr., followed an hour later by an injection of morphia, atropine and codeine phos. gr. 4. A tourniquet had at once been applied to the arm, and as soon as the patient lost consciousness, an amputation was made, without evoking any sign of pain from the patient. Recovery good.

Dionin and Its Use in the Abstinence Cure of Chronic Morphinism.-A. FROMME† gives his experience with this new preparation made by E. Merck. Dionin is an ethyl-morphine. It is superior to codein and peronin, in that it is easily soluble in water and is painless in hypodermic injections. The normal dose of an individual who is not a chronic morphinist is 0.015 to 0.03 grams. In cases of chronic poisoning, the dose can be made much higher, depending upon the quantity of morphine used by the patient. The method of treatment pursued by Fromme is as fol. lows: As soon as the daily dose of morphine has been reduced to 0.04 to 0.02 grams and the patient feels fairly comfortable, the morphine is withdrawn altogether and dionin is substituted. At first it must be frequently given, but soon only two or three doses a day are necessary. A 3 per cent solution of dionin is used and 0.05 to 0.08 per injection is given. The only bad after-effects observed was a temporary erythema, which soon passed away. The dionin may be given indefinitely. The author recommends dionin most highly.

Subcutaneous Rupture of Large Arteries from Contused Wounds.-J. A. CROOK‡ cites a case of rupture of the brachial artery; contusion of the soft parts above and below the elbow, with fracture of the neck of the radius, the skin remaining intact.

*Lancet. April 22.

+ Berl. klin. Wochenschr., April 3, 1899. Jour. Am. Med. Assn., May 13, 1899.

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relieve tension and swelling, several punctures were made into the tissues and the arm dressed with hot bichloride solution. The thumb and fingers assumed the condition of dry gangrene after several days. Twenty-one days after the injury the line of demarcation was plain, and the arm was amputated above the elbow, patient making rapid recovery. In discussion, Cook emphasizes the importance of search for the pulse in all cases of severe contusion. The signs of obliteration may be retarded, depending upon whether there is complete rupture of the artery or whether only the middle and inner tunics are involved; the latter condition may lead to aneurism or secondary hemorrhage from rupture. Treatment should be conservative, with strictest antiseptic precautions. Amputation is the only measure if gangrene supervenes.

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Treatment of Acute Rheumatism. — H. B. FAVILL* outlines a routine, but says that no case should be treated by a predetermined plan: 1. Empty the bowels; preferably with a mercurial. 2. Administer salicylate of sodium to its full analgesic effect; if not well borne, give oil of wintergreen. If it is contra-indicated by cerebral conditions, use antipyrin or the coal-tar preparation best adapted. these are contra-indicated by the condition of the heart or nervous system, use opium; at all events control pain. 3. As the pain is controlled by such means aided by local measures, particularly heat and immobilization, gradually withdraw the salicylate and saturate the system with an alkali, continued till the active process seems controlled. 4. Finally, while giving the alkali, or after it, administer iron if the condition of the bowels and liver permit; at all times promote intestinal hygiene by mercurials, cholagogues or salines.

Quinine in Malarial Hemoglobinuria.-C. C. WARDEN says there is nothing to prove that quinine is ever harmful, except in cases of pure quinine-hemoglobinuria. The administration of quinine should depend upon the results of blood-examination. He gives the rules of Bastianelli: (1) if hemoglobinuria occurs during a paroxysm and parasites are found, use quinine; (2) if parasites are not found, do not use quinine; (3) if quinine has been used before the hemoglobinuria began, and there are no parasites, discontinue the quinine. The blood destruction in the vessels during malaria continues so long as the parasites are present, and it seems advisable from this fact alone to administer a drug that is specific in its action and is able to check the hemolysis. The exhibition of quinine, therefore, should depend upon the presence of the parasites, and if these are present, a dangerous idiosyncracy is the only condition which necessitates the entire withdrawal of the drug.

*Jour. Am. Med. Assn., May 13, 1899. +Phila. Med. Jour, May 13, 1899.

Practical Therapeutics.

The Treatment of Diabetic Coma.-An increasing knowledge of the dietetics of this disorder teaches the profession that strict adherance to antidiabetic food favors the development of coma. While the exclusion of carbo-hydrates lessens the amount of sugar in the urine and thus overcomes one sympton of the disease, it is doubtful if the diabetes is improved by the lessening of the sugar, in the majority of cases. Greater benefit is to be derived from lessening the carbo-hydrates than from their total exclusion. The presence of acetone in the urine should at once direct the attention of the physician to the possibility of the development of coma. Even when this is not noted, the peculiar odor of new-mown hay in the breath or a marked lassitude in the patient should be sufficient to direct the attention to this possibility. These symptoms should be followed by an abrupt change from an antidiabetic diet to a strict milk diet. Saline purgatives should be administered to clear out the intestinal tract, as it is possible that diabetic coma may have its origin in fermentations in the intestinal tube. Bicarbonate of sodium should be administered in large doses to overcome the lessened alkalinity of the blood. If coma develops, the following solution should be injected into the colon:

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If this is not followed by some relief, the same solution, properly sterilized, should be given hypodermically; or in cases of great urgency it may be thrown into the veins.

Bottini's Operation in Enlarged Prostate.-The Bottini operation is a galvano-cautery destruction of a portion of the enlarged prostate. His instrument closely resembles a lithotrite. Introduced with the blades closed and carried behind the projecting portion of the prostate, the current is turned on and the upper blade is raised to a temperature that will destroy the tissues and is then moved gradually through the substance of the prostate, in extreme cases several incisions being made. The immediate result is to relieve obstruction and the remoter effect is to cause an atrophy of the remaining portion of the prostate. The operation has met with considerable success, particularly in cases in which the bladder is not extensively diseased. After secondary infections of the genito-urinary tract, it is probable that suprapubic cystotomy, with its perfect drainage aad control of operative procedure, will be the method of election. In cases of simple obstruction, without severe complications, the operation of Bottini is the preferable one.

Suprarenal Gland in Chloroform Anesthesia.— The ingenious suggestion has recently been made regarding the value of desiccated adrenals in chloroform anesthesia. It has recently been determined that the medullary portion of this gland contains a substance which contracts the arterioles and enormously raises blood pressure. Late theories regarding death and chloroform anesthesia attribute it to the sudden and marked fall in vascular pressure. It would seem that in the desiccated adrenals we have a direct antidote to the action of chloroform. Of course, it would be impossible, after dangerous symptoms present them

selves, to administer the extract, as it would then be too late to have it absorbed even from the cellular tissue, to say nothing of absorption from the alimen. tary tract. The remedy, to be efficient in preventing accidents from anesthesia, should be administered a few hours or perhaps a day before the operation, in that way directly antidoting the tendency that chloroform has to produce an abrupt fall in vascular pressure.

Cardiac Weakness.-ROBISON states that, in his opinion, when great physical strain is eliminated, attacks of acute cardiac dilatation are found as the re. sult of the presence of toxic materials in the blood. Cardiac weakness is more common than is generally supposed, which fact should always be remembered in the treatment of infectious diseases. In acute disease the best remedies are strychnine, spartein, electricity, and oxygen. In convalescence, digitalis, convalaria majalis, and strophanthus.

Open-Air Treatment of Phthisis.-Recent medical literature contains numerous articles in which the value of the open-air treatment of consumptives is amply attested. The climatic treatment of this disorder has long been a favorite with the profession, and comparatively few patients having the necessary means, but are advised to seek the Southwestern portion of the United States, or other regions especially favored by moderate temperature and comparatively dry atmosphere and freedom from marked changes of temperature. For a long time it was believed that the climate of these regions possessed some specific effect in the treatment of pulmonary tuberculosis. Later observations, particularly those at Saranac Lake, and other regions less favored by an equable, dry and even temperature, have shown that the effects of the climate of New Mexico and adjacent regions. may in some measure be due to the open-air life led by patients, the increased exercise and the improved nutrition resulting therefrom. There is no intention on our part to disparage the effects of a dry, elevated, and even temperature in the treatment of these disorders, but unfortunately, the expense attending the journey to these regions and the prolonged sojourn away from home is beyond the reach of a large pro

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portion of consumptives. The disease is most common in those of limited means who are daily confined to an indoor occupation; factory operatives furnish a considerable proportion of those afflicted with this disorder. It is in this class of cases that we should especially urge a change of occupation and getting them out of doors. Frequently this simple means will result in recovery in the early stages of the affection. The experiences of sanitoria in this and other countries confirm the value of open-air treatment. may, of course, be combined with the administration of tonics, nutritives, or, what is perhaps of more value, some of the later products obtained from the tubercle bacillus, which undoubtedly have a favoring influence upon the tubercular process. The danger in relying upon drugs or other means of combating tuberculosis is, that they may be used to the exclusion of the open-air treatment, which is the most universally applicable of all methods in the treatment of this disorder. The inclemency of the weather in the central portion of the United States often makes it difficult to persuade patients to live out of doors, but the results achieved in the New York institutions show that cold, high winds, and even rain, by no means contra-indicate out-of-door life, particularly when the patients are suitably clothed and are under medical supervision.

Digitalin in Heart Failure. The want of compensation in the heart's action is met by a variety of therapeutic resources. The Schott bath, passive and regulated active exercises, as well as respiratory gym. nastics, all tend to a restoration of cardiac balance. In acute cases, the immediate use of those substances which dilate the peripheral arterioles and thus lessen the distal resistance of the circulation, as well as those which increase the force of the heart's action, are indicated. The rapidly acting strychnia is undoubtedly the best remedy in acute cardiac failure, but it is not appropriate for prolonged administration; not that it does harm, but its continued admin. istration is accompanied by a tolerance of the drug and it soon ceases to have a marked effect on the heart's action. Clinical experience shows that digitalis is a true heart tonic. The most usual form of its administration is the tincture, but this preparation contains certain substances which increase the peripheral resistance and raise vascular pressure. Digitalin is not open to these objections. It is a pure heart tonic which increases the force and frequency of the heart's action and strengthens the heart muscle. By some writers it is believed that it favors cardiac hypertrophy. It should be given in increasing doses, beginning with a forty-eighth of a grain, then with a twenty-fourth and possibly a twelfth; indeed, it is best not to have a distinct dose, but rather to be governed by its effect upon the

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a want of compensation it is probably the most valu. able remedy that we have. Tolerance is not readily established and the drug may be continued for long periods with favorable effects.

Ovarian Extract in the Treatment of Nervous Disorders of the Climacteric.-Most recent writers are agreed that the disagreeable symptoms of the natural or artificial menopause are relieved by the exhibition of ovarian extract or desiccated ovaries. Not only do the unstable nervous conditions improve, but the nervous flashes, pain in the head and other disturbances in the circulation are quite rapidly relieved. Often the local conditions which are sometimes associated with this condition improve at the same time. The dose of the desiccated ovaries or of the extract is from three to five grains twice or thrice daily. Preference is usually given to the administration in capsules, but it may be administered in wine or other liquid.

Largine in the Treatment of Gonorrhea. This substance is the most recent of all the new preparations of silver. It is described as a light-gray powder, easily soluble in water, feebly alkaline, and may be kept indefinitely in colored bottles. Its action closely resembles protargol, but it is said to be much more energetic. Virulent cultures of the gonococcus are said to be destroyed after ten minutes in one to four thousand solution. The usual strength of urethral injections is from one to two hundred, gradually increased as tolerance is established. It has been employed in endometritis, cervical metritis, and the inflammations of the urethra and bladder due to the gonococcus.

The Prevention of Cinchonism.-The disagreeable effects of cinchona and quinine are brought about in two ways: either by an excessively large dose, the indications for which are furnished by the conditions which demand the use of the drug, or an idiosyncrasy on the part of a patient, by which a moderate or even small dose produces ringing in the ears, dizziness and other severe symptoms. Perhaps the most certain and efficient method of overcoming these symptoms is to accompany the administration of the quinine with moderate doses of bromide of sodium. In some cases hydro-bromic acid is given, but the dose is usually too small to obtain the peculiar effects of the bromide in antidoting the quinine. Undoubtedly the most efficient means is the administration of a liberal dose of bromide of sodium, fifteen to thirty grains, given with the quinine. Ergot modifies the untoward action of the drug, due to its tonic effect upon the cerebral blood-vessels. A recent writer, Aubert, claims that atropin, given with the quinine, markedly overcomes the symptoms of the latter drug. The dose should be from to ʊ gr.

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Treatment of Hay-Fever.-WRIGHT tells us that two new drugs promise well-orthoform and suprarenal gland. Orthoform will allay the sensitiveness and the paroxysmal sneezing. Its effects are much more enduring than cocain, and it has no toxic action. When we wish to give the patient free breath through the nose and lessen the serous discharge, a solution of supra-renal extract will accomplish the result without the disadvantages of cocain. recommendations of Wright are of considerable value and they especially appeal to the conscientious practitioners who wish to avoid the use of cocain in the nose. We feel sure that no patient should be allowed a prescription containing cocain for self-application to the nose, as the risk of forming the habit is one which cannot be over-estimated. The copyrighted catarrh cures which almost invariably contain cocain already number so many victims that the physicians must not add to their number. Orthoform is stated by Wright to be free from toxic effects. Some late writers, however, claim that it does cause some degree of intoxication, but the danger from it is probably not great. Certainly it is not nearly as dangerous as cocain. The supra-renal extract has a marked effect upon the peripheral circulation, and it is doubtless quite harmless. Whether permanent results can be reached by its prolonged administration remains to be demonstrated by further trials.

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Tetanus and Antitetanic Serum. DR. L. MARSHALL* reports a case of tetanus in a girl of 12 years, successfully treated with the serum. Patient, who had been burnt on the arm and treated at home, was admitted two weeks later with pain in neck and back, difficulty in swallowing; later the head became retracted, mouth tightly closed, risus sardonicus, followed the next day by opisthotonus and contraction of the abdominal muscles. An injection of 5 c. c. of serum was made, followed 8 hours later by a similar injection. She slept well that night, but the next day was seized with a tonic contraction of the respiratory muscles in the morning, and a similar attack in the afternoon; 10 c. c. of serum were injected that day and 20 c. c. the next, while 20 grs. of potassium bromide and 10 grs. of chloral hydrate were given every 6 hours. The next day the condition was somewhat improved, and 10 c. c. of the serum were injected. For the next four days, the improvement was gradual, and each day 10 c. c. were injected. From this time forward the patient got steadily better. 110 c. c. were injected in 9 days in 12 injec

tions.

On the day after the last injection a papular rash appeared on the left thigh, and a typical urticaria on the right, both disappearing in 24 hours; 6 days later a papular rash appeared on the trunk and limbs, lasting four days. Night temperature was 102° throughout.

*Lancet, April 22, '99.

Bromide of Strontium in Epilepsy. The disturbances of nutrition caused by the potassium salts of bromine when administered in large doses, for a considerable length of time, form a serious objection to the use of these salts. The different actions of the bromide salts show that it is more than the quantity of bromine in the individual salt that determines its remedial as well as its harmful action. The results reached in the administration of the salts of strontium show that this recent addition to the materia medica

is exceedingly valuable. It may be administered in larger doses and for a longer time than either the bromide of potassium or the bromide of sodium, and its effect upon the digestive processes as well as the nutrition are nothing like as unfavorable, while in suppressing epileptic seizures it is quite as efficient. The Treatment of Tubercular Cystitis by Insufflation of Sterile Air.-The obstinacy of this affection makes any suggestion regarding its successful management of considerable value. REYMOND has noted the excellent results of laparotomy in the treatment of tuberculosis, and was led to try substantially the same methods in the treatment of tubercular infection in the bladder wall. His method is to introduce a sterilized catheter which is connected with a syringe of 100 c. c. capacity. All air is filtered through a pledget of cotton wool. At first the bladder is distended gently and the air allowed to escape. The inflation is repeated, each time with slightly greater force so as to fully distend the organ. The last insufflation is allowed to remain by suddenly withdrawing the catheter. It is stated that the method is quite painless and followed by prompt improvement, the pain, difficult micturition, and other symptoms rapidly disappearing. Of three cases reported, all were relieved within a short time.

Restriction of Fluids in the Treatment of Aneurisms.-LAACHE* recalls the fact that what was known as the Toufnell cure consisted of a systematic diminution of both fluids and solids of the diet. The Toufnell diet consisted of 60 gm. of milk with 60 gm. of bread and butter for breakfast; for dinner 90 gm. of meat with 90 gm. of potatoes or bread and 120 gm. of Bordeaux wine; the evening meal was restricted to 60 gm. of milk or tea and 60 gm. of bread and butter. A somewhat similar plan was followed by Laache. The patient, who was suffering from an aneurism of the aorta, the size of an apple, lived for five years. During most of the time, small doses of sodium iodide were given, and it was occasionally necessary for him to remain in bed for a time. theory of this treatment is based on the view that a restriction of the fluids and a decrease in the diet favors the development of coagula in the sac by increasing the specific gravity of the blood.

*Therapie der Gegenwart.

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