Now that faith in the system has become established, and so much confidence is felt in the management of two such fatal diseases, physicians are beginning to more generally apply the same principle in the treatment of others of less virulence. Among these is erysipelas; and, in my personal experience, and in that of others who have published reports of cases so treated, the results have been so uniformly good-so much better, indeed, than were ever obtained by any other mode of treatment—that at the present time I should as soon think of omitting antitoxine in diphtheria as Marmorek's serum in cases of erysipelas. At the very beginning of his paper Professor Winter says quite truly that erysipelas is "due to the presence of a streptococcus," and why he did not recommend the destruction of this microbe in his otherwise reasonable plan of treatment I am at loss to know. "Remove the cause" is one of the first things I remember to have heard from my old teachers in their instructions for the treatment of all classes of disease, and it is one of the last things that I endeavored to impress upon a class of students before retiring from the lecture arena. Remove the cause sufficiently early, and you either prevent or abort the disease; remove it later in its progress, and you have then but the complications and sequelæ to deal with. "Remove the cause" is most excellent therapeutic gospel today, as it has been in the past, and must remain throughout the realms of futurity. Now, is it always possible to do this in cases of erysipelas, or, in other words, in cases of streptococcal infection, no matter what may be the disease in which it occurs? Unhesitatingly and most positively I answer, yes. Perhaps it would be well to explain that this answer is based upon clinical experience in multiplied dozens of cases in my own practice and in that of medical friends, to say nothing of the hundreds that have been mentioned by writers both in this country and in Europe. In answer to the (assumed) retort, that a number of failures have also been reported, my reply is, why, of course. Water has often failed to drown people; it has even failed to quench thirst or cleanse a piece of linen, but it will do all of these if properly applied in sufficient quantities. I have taken the pains to investigate and analyze a number of the socalled failures of Marmorek's serum to do the work claimed for it by its discoverer, and without exception, I believe, the failures were readily traceable to faulty administration, either as to time, quantity or quality of the serum. The time to use the serum in order to get the very best results is at the earliest possible moment, and this holds good in the use of all antitoxines and blood serums. No doubt many a precious life has been sacrificed by delay in the use of the remedy. Quantity in blood serum is precisely the same as quantity in any other remedy-it requires a definite amount to produce definite results. Marmorek's serum, like all of those prepared at the Pasteur laboratories in Paris, contains no antiseptic whatever, and the quantity safety is practically unlimited. This is an of it that may be given with absolute important point to remember. It is not the antitoxic power of a serum that renders it unsafe to exhibit in large doses, but it is the impurities of the product, usually in the form of extraneous substances put in for their supposed preservative power. As to quality, it must be remembered that the genuine Marmorek serum is made in but one quality, as well as in one strength; but it must also be remembered that blood serums soon deteriorate if not properly kept, and Marmorek's is no exception to the rule. So that, while Marmorek's serum will retain its properties for ten or twelve months under ordinary conditions, a little carelessness on the part of a dealer, such as keeping it near a stove or other heating apparatus, would cause it to lose its potency in a very short time. Serums keep best at a temperature ranging from 40° to 60° F., and consumers of these products should always make sure that their purchases are made from dealers who have both the facilities and the inclination to so keep them. So much for the remedy itself. Now, as to the disease and its general management. The treatment which I follow in a case of idiopathic facial erysipelas is the simplest, easiest applied and, I believe, the most efficacious of any yet proposed. It consists in the subcutaneous injection of 20 c.c. or 30 c.c. (according to the severity of the case and the stage at which treatment is begun) of Marmorek's serum, and covering the affected area with a poultice of antiphlogistine a quarter of an inch thick, and placing over this a layer of absorbent cotton. If this is done early in the attack, one dose of the serum will "remove the cause," and a single application of the dressing will complete the cure. If, however, for any reason the disease does not yield in the manner just mentioned, both serum and dressing should be renewed at intervals of twenty-four hours until it does so. By this method of treatment all stomach medication is dispensed with, unless it be an occasional saline laxative or purgative. All nasty, disfiguring and otherwise offensive local applications are rendered unnecessary, and, in the vast majority of cases, the stage of convalescence is so brief that the time-honored iron tonics are gladly passed over for a nutrient diet. When tonics are indicated, however, I prefer dialysed iron or pepto-mangan to the tincture of the chloride, because they do not injure the teeth, they do not upset the stomach and they do not constipate the bowels-all of which the tincture would surely do in my patients if given in anything like the doses mentioned by Professor Winter. In some of the severe forms of erysipelas, such as that following parturition and various traumatisms, the sailing may not be quite so smooth, for then we have a variety of complicating influences to combat; but even in the worst of these the sheetanchor is undoubtedly to be found in the realm of serum therapeutics, and no case should be abandoned as hopeless until the "microbe killer" has been thoroughly tried. THE TREATMENT OF LATENT DYSPEPSIA.-M. Albert Robin states in the American Journal of the Medical Sciences that if the stomach does not perform its work this failure can be completely supplied by the intestine. Ref erence is made to the total ablation of the stomach of a dog by Frémont. If the conclusion is reached that the stomach is not indispensable, it does not follow that latent dyspepsia is not without its inconveniences. If, however, the intestine fails, then the symptoms of dyspepsia appear and dominate the scene. To obtain a cure the constipation must be relieved, and for this these measures should be cmployed: (1) Purgatives, particularly drastic purgatives in small doses, for these are not followed by constipation, as are the salines, which necessitates their continued use; (2) gentle and methodical massage of the large intestine, and (3) the use of mineral waters, as Châtelguyon, Brides, Aulus, Kissingen and Carlsbad. Albuminuria of dyspeptic origin is frequent; there also exists a dyspeptic diabetes, and these require treatment which is not usually considered in the discussions upon the therapy of these conditions. VENESECTION IN PUERPERAL ECLAMPSIA.-Van Roojen (British Medical Journal) was called in to a case of severe eclampsia folowing delivery. There were convulsions, albuminuria, edema and syanosis. He opened the median cephalic vein and bled to 400 g. At once the patient began to improve, and no more fits occurred, although at the end of a month an hysterical attack was noted. An injection of 20 mg. of hydrochlorate of morphine was given after the bleeding. The improvement in the pulse was very distinct directly the heart had been relieved of a greater amount of blood than it could easily impel. Lambinon of Liége also reports a case of puerperal eclampsia successfully treated by venesection. SUMMARY OF THE EXAMINATION HELD BY THE BOARD OF MEDI CAL EXAMINERS OF MARYLAND, MAY 18, 19, 20, 21, 1898. A general average of 75 being required, it will be seen from the above table that of seventy-two failed to reach that average. Surgery........ Pathology..... 100 98 98 100 100 Physiology.... 876371 222 96 83 72 Anatomy....... & K X X NA I OKO WARRI 45 80 96 100 55 95 100 100 78 90 85 83 90 96 100 83 83 71 57 100 85 73 95 100 83 96 92 58 75 100 80 72 80 100 Baltimore Medical College...... University of Maryland..... SUMMARY OF SCHOOLS. Passed. Failed. Passed. Failed. College of Physicians and Surgeons... 9 1 ANATOMY. 1. Describe the collateral circulation after ligation of the right subclavian artery. 2. Name the chief veins of the lower extremity. 3. Describe the elbow joint. 4. Name the different kinds of glands of the small intestine, and tell where they are to be found. 5. Describe the gall-bladder. 6. Give a general description of the stomach, omitting its structure and minute anatomy. PHYSIOLOGY. 1. What are the direct sources of animal heat? What functions govern the temperature of the body? 2. What is a reflex action? Give an example. 3. What are the functions of the medulla oblongata? 4. What would be the result of a transverse section of one lateral half of the gray matter of the spinal cord? 5. What circumstances influence the amount of carbon dioxide excreted? 6. What part of the digestive process do the following organs perform: The salivary glands, the stomach, the pancreas and the lacteals? SURGERY. 1. Give diagnosis and treatment of renal calculus. 2. Name and describe three varieties of gangrene. 3. Give the treatment of a fracture of the clavicle. 4. Give the treatment of a dislocation of the shoulder. 5. Give the diagnostic points of difference between an intracapsular fracture and a dislocation of the femur upon the dorsum ilii. 6. Describe the operation of tracheotomy and the conditions requiring it. HYGIENE. 1. What is a disinfectant? 2. What is the difference between an infectious and a contagious disease? 3. What are the indispensable features of a schoolroom constructed upon hygienic principles? 4. Name the chief sanitary requisites of a healthy site for an encampment. 5. What diseases are produced wholly or in great part from impure drinking water? PATHOLOGY. 1. Give the morbid anatomy of bronchopneumonia. 2. Give the morbid anatomy of tuberculous laryngitis. 3. Describe the morbid changes in arteriosclerosis. 4. Give the morbid anatomy of leukemia. 5. Give the morbid anatomy of carcinoma of the liver. 6. Describe the morbid changes in acute pleuritis. CHEMISTRY. I. What are the physical and chemical properties of water? 2. What is bromine? Its physical properties? Its chemical properties? Where does it occur in nature and how is it prepared? 3. By what tests can starch be recognized? 4. How may antimony be distinguished from arsenic? What is the composition of tartar emetic? 5. Give the chief tests for copper. 6. Name the principal compounds of iron and sulphur. (Give formulae.) 7. How would you distinguish the following chemical deposits of urine: (a) Urates or lithates, (b) earthy phosphates, (c) uric acid, (d) oxalate of calcium? 8. What are the properties of urea? How is it prepared? MEDICAL JURISPRUDENCE. 1. What are the post-mortem appearances of death by drowning? 2. What are the symptoms of poisoning by aconite? By oxalic acid? 3. What are the primary causes of death by wounds? 4. What are the signs of live birth? 5. What are the signs of recent delivery in the living? PRACTICE. Answer any 8 questions in this paper and no more. I. Describe the mitral regurgitant murmur. Give the topography of the chest, showing where the sound is best heard. 2. Give the differential diagnosis of ulcer and cancer of the stomach. 3. Diagnose between ascites and fluid in an abdominal cyst. 4. Give the diagnosis and treatment of cholera infantum. 5. What are the most common causes, and what are the symptoms of cirrhosis of the liver? 6. Give the treatment of intestinal hemorrhage in typhoid fever. 7. Give the physical signs and treatment of croupous pneumonia. 8. What are the common causes of jaundice? 9. Give symptoms, diagnosis and treatment of catarrhal gastro-duodentis. 10. What is Bell's paralysis? Give causes and symptoms of same. MATERIA MEDICA. 1. What is camphor? What are its officinal preparations? How are they used? What are the doses? 2. How is paraldehyde made? What are its uses? What is the dose? 3. From what plant is sumbul derived? What officinal preparation is made of it? How is it used? What is the dose? 4. What are the principal medicinal preparations of calcium? 5. To what class of remedies does santonine belong? What is the usual dose and how is it best administered? 6. Name three remedies belonging to each of the following classes: (a) Antizymotics, (b) disinfectants, (c) parasiticides. THERAPEUTICS. 1. What is the usual adult dose of (a) pilocarpine, (b) sulphide of calcium, (c) picrotoxin, (d) tincture of strophanthus? 2. Give the botanical name and therapeutic uses of witch-hazel. 3. What is the physiological action of digitalis in its medicinal and toxic doses? Give antidote and antagonists. 4. Give the common name and therapeutic uses of elaterium. 5. What are the therapeutic uses of thyroid extract? 6. Mention the therapeutic uses of the bromides. OBSTETRICS AND GYNECOLOGY. I. Give the diagnosis and management of an occipito-posterior presentation. 2. Describe the first and second stage of normal labor. 3. State your management of the third stage of labor. 4. Give the diagnosis and treatment of subinvolution of the uterus. 5. Give the definition and your treatment of puerperal eclampsia. 6. Define and give your treatment of puerperal phlelitis. 7. What is uterine involution? What time is usually required for its completion? What may delay or prevent it? 8. Name conditions which may be mistaken for pregnancy, and give differential diagnosis? Medical Progress. SURGICAL HINTS.-The following surgical hints are given by the International Journal of Surgery: In giving chloroform, beware of the patients who fight and struggle. They are the ones which furnish most of the mortality. Avoid carbolic acid as a dressing in children. Many cases of hematuria and other renal complications have attended its employment in the young. In injuries of the spine with myelitic symptoms bed-sores may occur with startling rapidity. They should be guarded against from the very first. Some children with phimosis also suffer from prolapse of the rectum, which is often cured by the performance of circumcision. In ingrowing toenail, if operation is refused by the patient, the introduction of a layer of tinfoil between the nail and the inflamed surface is probably the most effective procedure. In hernia of small children, when the intestine has descended into the scrotum, it often is translucent, whereas in adults it is not. Hence, hernia in small children has been punctured under the impression that the tumor was of a cystic nature. The amount of absorbent dressing over a wound should be gauged by the probable amount of effusion of blood and serum likely to occur. It is better to err on the side of extra-copiousness. scanty dressing necessitates frequent change, since saturation of the covering defeats purposes of asepsis. A In rectal abscess, whether marginal, ischio-rectal, intermural or perirectal, the surgeon should operate as early as possible. Use anesthesia, if possible, as the incision should be a very free one. small opening is most likely to produce fistula. This can only be prevented by a large incision, drainage, and keeping the external orifice open. In head injuries, an artery of the brain may have been injured without bleeding until after reaction has taken place. Many a patient has shown symptoms of cerebral concussion, and apparently rapidly recovered, who has been permitted to get up, and has died suddenly a short time afterwards. Rest for several days after such injuries should be imperative. Always remember that in strangulated hernia, if unrelieved, death only takes place, on an average, about six or seven days after strangulation occurs, though much longer or shorter periods have been observed. Many patients are told they will only live a day or so unless operated on, who linger for several days more, and, finding that they do not get worse as rapidly as was expected, maintain a false hope of recovery without operation. |