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tion of the bowel with a saturated solution of boric acid in water. If the infant be much prostrated, irrigation will hasten the end. Iced champagne and iced brandy may be given to quiet the stomach. Mustard papers should be applied to the abdomen often and long enough to keep the skin red. Fever should be combatted by baths; cold extremities and subnormal temperature by hot bottles. The severe symptoms last about twenty-four hours. With abatement of vomiting, all stimulation may be by mouth. Food must be tried slowly and in small quantities. One of the best for this purpose is Valentine's meat juice. I have had it retained when the stomach would accept nothing else. Continuance of diarrhea after subsidence of other untoward symptoms is regarded an entero-colitis, under which head the treatment will be further considered. The writer wishes, in conclusion, to emphasize that nothing must be given by mouth, not even champagne or brandy, unless they exert a modifying influence, when the stomach is irritated; that the hypodermatic form of medication is the only one applicable to these cases; that whiskey and strychnine hypodermatically are the most ef fective agents at our disposal for keeping up the strength; lastly, that no antipyretics should be administered, but rely upon baths to reduce fever. It is needless to add, an experienced nurse should always be in attendance, when possible. Do not use ice caps to control convulsions and thereby increase the anemia of the brain, to which they are largely due.

Entero-colitis.- We have just seen that cases of acute dyspeptic diarrhea, and cases recovering from an acute attack of cholera infantum, may terminate in an entero-colitis. On the other hand, cases of cholera infantum may develop from an entero-colitis. There may be an acute, subacute and a dysenteric form. The forms are easily distinguishable when we once gain clear conception of what constitutes an enterocolitis. From the nature of my paper, I shall have to content myself with giving but a few symptoms of the trouble

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under consideration before referring to its treatment. Cases going to autopsy, of which I regret to say I have seen many, reveal certain lesions of the bowel, and for the consideration of which I must refer you to works on pathology. These cases have a continued fever not high except in acute attacks at times. When the intestinal secretions are locked up or became scanty, we usually see a rise of fever. There is as a rule no vomiting. The nervous symptoms are manifest, but not so violent as in cholera infantum. The tongue soon becomes glazed, red and cracked. Emaciation is steady. The stools are characteristic. They contain much detritus in the form of undigested food quite frequent, from four to twenty a day; they are not, as a rule, particularly offensive; much mucus is found in them, at times streaked with blood or containing blood clot. Nothnagel makes a good point, the less the mucus is mixed with the feces, the lower down in the bowel it comes from. The same remark may apply to blood. There is much tenesmus and occasionally prolapsus ani. The color ranges from yellow to grass green. The green color of the stools has never received a generally satisfactory explanation. The addition of lime water to a yellow passage will cause it to turn green in three to twentyfour hours. This fact leads me to the conclusion that the green color is due to the conversion of bilirubin into biliverdin, either directly or indirectly by some special micro-organism acting in an alkaline medium. That the action is an indirect one, requiring special conditions, seems the most rational explanation to me.

Treatment. Simple diarrheas should not be allowed to run on to an enterocolitis. Opium when the stools are frequent and temperature not very elevated. On the other hand, when stools are scant and the fever rises, castor oil is indicated. Bismuth and salol in combination are invaluable. Extract of pancreas should never be given by the mouth. It is destroyed in the stomach by the combined action of pepsin and hydrochloric acid. Some authorities claim

that but little digestion goes on in the stomach of sucklings, that its function is largely that of a reservoir. Judging from the nature of the food and from the known activity of the pancreatic juice in infants, I am inclined to the same opinion. I am therefore opposed to the administration of digestive ferments to infants. I have seen on the autopsy table, in marasmatic infants, more than one stomach wall in various stages of digestion. In view of the fact that those infants were greatly emaciated, in most cases, and immediately sent to the dead-house, and therefore soon cooled below the point when artificial digestion is most active, I can not satisfy myself that the extensive changes found were due to post-mortem self-digestion.

It is in these cases that predigested and prepared foods are particularly valuable. The kind to use must be determined by experience and by an examination of the passages for fat and casein.

Irrigation gives good results. My preference has been stated. Tannic acid when stools are frequent, boracic acid when scarce. In cases of dysenteric nature high irrigation with about one pint of a nitrate of silver solution (gr. j to 3j) followed, without withdrawing the tube, by a copious weak saline solution, does good. Once a week is sufficiently often to use this. I have also obtained good results with nitrate of silver, in pill form, by the mouth in these cases when the small bowel is more affected. The great drawback to this way of using the drug is the difficulty in getting an infant to swallow even the smallest pill, though they can swallow pins readily.

Chronic Diarrhea. It is unnecessary for me to go into detailed description of the manifold phases of chronic diarrhea. Treatment must be regulated by the practitioner to meet individual cases.

SPINAL CORD DISTURBANCES AFTER TYPHUS FEVER.- Dr. S. Terzykowski (Universal Medical Journal) has examined three cases of nervous disturbances after typhus fever. One case recovered, but the others did not. The question

The practice of giving opium and astringents to confine the bowels one day and an aperient or purge the next, or vice versa, must be condemned as unscientific. Nature's tonics in the form of fresh air and proper sanitary surroundings, united to a suitable food, are our mainstays. Irrigation of the bowel does good in infants not too much weakened by the disease. If we have reason to suspect an ulcerative condition, the nitrate of silver injection will likely do good. Theoretically, the fluid extract of coto bark seems to be the drug for these cases, exerting, as it does, an antifermentative action and, at the same time, bringing a healthy supply of blood to the intestines, by causing an active dilatation of their vessels. It has been tried and found wanting. The best we can do in these cases is to pay due attention to the rules of hygiene; administer antifermentatives as indicated, the best of which is salol; avoid the routine use of astringents; and lastly, give suitable tonics where indicated.

In conclusion, I would say that the treatments I have endeavored to outline for these affections are not new, nor are they the only ones. Still, after much experimentation on many hundred cases, coupled with no little study of the subject, the treatments outlined appealed to me as giving the best results. Drugs must take a secondary place to dietary in these cases. "Shot-gun" prescriptions are to be avoided. Understand the conditions you are to combat and select the best drug for that purpose. Drugs that do no good do harm. It is much easier to upset a child's stomach than to quiet the same. Leave new drugs and proprietary preparations for your neighbor to experiment with. Bearing these facts in mind, working systematically, plainly and carefully and success will crown our efforts where success is possible.

as to whether these disturbances are occasioned by the typhus bacilli or by their toxic products has not yet been solved. The noxious factors reach the nervous centers through the lymphatics, bloodvessels and the peripheral nerves.

UREMIC COMA.

READ BEFORE THE BALTIMORE MEDICAL ASSOCIATION, NOVEMBER 26, 1894.
By John I. Pennington, M. D.,

Baltimore.

THE case that I am about to relate is, in my experience, unique. In a practice of twenty-five years I have seen nothing like it. On November 14, about eleven o'clock P. M., I was called to see a young lady, who, I was told by the messenger, was thought to be dying. On arriving at the bedside, I too thought her dying. She was lying in a state of complete relaxation, profoundly comatose. Her face, lips and finger ends were cyanosed; respiration abnormal, of the CheyneStokes character. The inspiration was short, a mere jerk. The expiration was prolonged, the air escaping by a collapsing of the lungs. At short intervals the respiration would be suspended, and at times for so long a period that one would think she had breathed her last. The pulse varied both in frequency and force. Occasionally it was intermittent. The nervous system, both motor and sensory, was for the time-being paralyzed. The reflexes were gone excepting a very slight closing of the eyelid on touching the cornea. No amount of slapping or tickling would excite the slightest movement. The muscular system was in a state of complete relaxation.

I do not think she made the slightest movement in the seven hours during which the coma lasted.

The history, as learned from the family, was unsatisfactory, and threw but little light as to the cause upon the case beyond the fact that they were quite sure she could not have taken any poison which would have produced the condition in which I found her. She was twenty-one years old, unmarried, and thought to be in fairly good health. She had for a few weeks been suffering from indigestion, for which she had consulted. her physician, Dr. Aronsohn.

of vomiting once during the day. She retired about 9.30 P. M., but before refiring she placed a wash bowl on a chair beside the bed, which would give the impression that she must have felt nauseated at that time. When her sister, who slept with her, retired about 10 o'clock, she was sleeping quietly, but in a short time, perhaps a half-hour, her sister was aroused by her breathing peculiarly. She could not be awakened by calling or shaking. On making a light her sister saw that she was alarmingly ill and called assistance. I was then sent for and found her in the condition as above described.

Diagnosis. The question as to the causes of all this disturbance was not at once easily answered, and it was especially difficult under the existing circumstances. The coma appeared to me like that occurring from uremic poisoning, but the absence of all symptoms except the nausea and coma made this conclusion doubtful. sion doubtful. I could learn of no symptoms preceding the attack indicating disease of the kidneys. There was no edema, and as far as we know the coma was not preceded by convulsions. The usual picture of uremic poisoning is somewhat like this: Edema, vomiting, convulsions and coma, with a history of an acute attack, or of failing health for some time previous. However, I believed that I had to deal with a case of uremia, presenting unusual symptoms, or I may say better, with the absence of some of the usual symptoms.

Treatment. The cyanosed condition of the skin, the character of the respiration, with the weakened and irregular action of the heart, suggested to my mind that whatever the cause, nitroglycerine hypodermically was the remOn the day of the attack she had as edy indicated, and I accordingly gave usual assisted in the household duties of a grain, repeating the dose in and seemed to be well with the exception one hour and also giving an occasional

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hypodermic of whiskey when the action of the heart became very weak. After working with her about one hour and a half, Dr. Aronsohn, the family physician, came. I then went home for a catheter and tests for the urine. On introducing the catheter we could get only two or three drachms of urine, which upon examination was found to contain albumen. A third dose of nitro-glycerine was now given, and in an hour we gave a hypodermic of digitalin. We had little hope of our patient recovering, for notwithstanding what we had done for her, there were no signs of improvement except perhaps that the cyanosis was not so marked. About 3 A. M., we again introduced the catheter and drew off two or three ounces of urine, which also contained albumen.

The question of giving a hot bath was suggested, but the patient was on the third floor of the house while the bath was on the second, and her condition was so precarious that we did not think it advisable to attempt to carry her down. We did apply heat to the back. Pilocarpine was also thought of, and the propriety of using it was discussed by Dr. Aronsohn and myself. But in

RESULTS OF PARTIAL RESECTION OF THE HUMERUS FOR SARCOMA. - Heurtaux (British Medical Journal) has recently reported a case in which eleven years ago he resected the upper half of the left humerus for a large and rapidly growing tumor which after removal was proved by very competent authority to be a true sarcoma developed at the expense of the medulla. According to the report of Malherbe, which was subsequently confirmed by Ollier, the malignity of the growth was placed beyond doubt. The patient, who at the time of operation was six years of age, was last seen by the author in the autumn of 1894. Then he found that there was not only a total absence of any indications of relapse, but also that the mutilated limb had proved a very useful one. Even when the arm was free, and not supported by any apparatus, the patient was able to lift and drag heavy

her condition of extreme relaxation, we thought best to rely upon the nitroglycerine and the digitalin.

She remained in about the same condition until about 7 o'clock A. M., when she commenced to show signs of improvement, and by eight o'clock she could be aroused to partial consciousness. About this time she improved rapidly, and at 10 o'clock, when I again saw her, she had sufficiently recovered to answer questions intelligently, but could give no account of her attack. She had passed urine in good quantity, which also contained albumen.

I did not see her after this, but Dr. Aronsohn informed me that the improvement had been uninterrupted, and that albumen had disappeared entirely from her urine.

I shall not attempt to explain the pathological condition, trusting that some one in the discussion will bring out this point. The points to which I wish to call special attention are the absence of symptoms of albumen preceding the attack, the suddenness with which it came, and the violence of the attack, and the most remarkable thing to my mind in the case was her recovery.

and resistant objects and could use the limb with sufficient precision to play on the piano. The left forearm and hand. were as well developed as those on the right side, but the arm was much wasted, being not more than eight inches in length, whilst the right arm measured nearly thirteen inches. The portion of the left limb between the shoulder and elbow was composed chiefly of soft parts, as the remaing portion of the humerus, the upper part of which was very thin, measured only four inches in length. This bone, since the operation, had undergone atrophy both in length and thickness. Notwithstanding this deformity the limb has proved so useful to the patient that the author holds that he is justified in advocating in cases of malignant growths of the head of the humerus a free resection of the upper part of this bone as a measure preferable to removal of the whole limb.

SOCIETY REPORTS.

BALTIMORE MEDICAL

ASSOCIATION.

MEETING HELD NOVEMBER 26, 1894.

Dr. E. D. Ellis, Second Vice-President, in the chair.

Dr. John I. Pennington reported a case of UREMIC COMA. (See page 224.)

Dr. J. Edwin Michael opened the discussion of this case. Uremia is but little understood. The term is based upon an error. Often we have these symptoms when no urea can be discovered. But something (we know not what) exists to cause the trouble. Dr. Pennington's case was unique. But we often have such a condition in pregnant women. He is unable to give the cause of the affection in Dr. Pennington's case. He referred to a paper by Hughes and Carter in recent numbers of the American Journal of the Medical Sciences, in which a case similar to Dr. Penning ton's is related. In the paper by Hughes and Carter experiments are mentioned of using blood taken from uremic patients to inoculate animals. The result was a nephritis produced in the animals. The blood of meat-eating creatures (man and the dog) will produce nephritis when introduced into the herbivora. Experiments of this character are of great importance in the etiology of Bright's disease. This leads. to the subject of vegetarianism which he is now investigating. He is now experimenting in his own person with vegetable diet to relieve neuralgic attacks, and with much benefit. In regard to treatment, the most important consideration is the elimination of the materies morbi by the various emunctories. The kidneys can be less relied upon for this purpose than any other organs. The most thorough elimination is obtained by venesection. Even it the pulse is feeble, bleed, and often the pulse will improve under the operation. To counteract depression we can inject saline solutions into the cellular tissue. The skin is the next most important emunctory. Hot packs are more useful

than baths. Pilocarpine is a drug of great danger. It causes great secretion of mucus. In regard to the alimentary canal, we cannot avail ourselves of this emunctory. Hypodermics of Epsom salt may be used, but they are not prompt enough.

Dr. John D. Blake asked if the eyes of this patient had been examined.

Dr. Pennington replied that they had not. There was no microscopic examination of the urine. The pupils were neither contracted nor dilated; they did not respond to light.

Dr. Blake: This case presented some of the features of hysteria. The case was peculiar. The rapid recovery was also remarkable. The presence of albumen during this short period without microscopic examination is not of much diagnostic significance.

Dr. David Streett: The patient had probably had nephritis previously. Such cases are frequently mistaken for hysteria. Nephritis may exist for several years without any evidence. He has many times seen patients who were insane, the condition being due to a nephritis. He thinks that if Dr. Michael will look up the question, he will find that the experiments mentioned by him. and considered to be new are in reality rather old. Pilocarpine does produce considerable diaphoresis and salivation, but it does not give better results than hot-air baths. This is one of the best methods of causing elimination, but it should be conjoined with the administration of fluids. Changes of temperature are a frequent exciting cause of nephritis.

Dr. Blake: One of the best things to be done in cases like this is to inject from a quart to a quart and a half of hot saline solution, with hot bottles applied. This plan together with venesection would be an ideal mode of treatment.

Dr. Michael reported the case of a young lady who he thought at his first visit was in hysterical coma. The urine was loaded with albumen. Everything was tried but venesection, and the patient died. He also reported a case of uremic convulsions in a pregnant woman, from whose urine albumen disappeared

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