salicylic acid. He thinks that they are both The work is one of great practical importance, A Treatise on the Principles and Practice of The sixth edition of this classic work on medicine is now before us. It has been revised Before the first edition was published special ate preparation, we do not wonder at the great eminence as an author which Dr. Flint obtained during his life. The present edition contains "a full consideration of recent discoveries concerning the bacterial origin of various infectious diseases as will be rendered evident by a consultation of the article on Vegetable Parasites in the chapter on Etiology, and chapters in the articles treating of tuberculosis, typhoid fever, cholera," etc. Dr. Flint was particularly fortunate in securing the services of Dr. Welch in the preparation of Dr. Welch is now one of the the fifth edition. most celebrated pathologists on the continent, and has added much to the value of this already celebrated work. The volume before us contains 1134 pages. We can recommend it as one of the best, if not the best treatise on medicine published in the English language, Lersonal. Dr. Ryerson, late of Church St., has removed to his new residence 60 College Avenue. MARRIAGE COURTENAY-MORRISON.-Sept. 18th, at St. George's Church, Guelph, by the Rev. George A. Harvey, J. Dickson Courtenay, M.B., to Minnie I., eldest daughter of R. B. Morrison, Esq., Merchant, all of Morriston. Miscellaneous. The same may be said with regard to this the sixth edition. "The careful and thorough revision of which this edition is the result," was practically completed by the late Dr. Flint in March, 1886, with the assistance of Dr. Welch. Dr. Flint, jun., thus speaks of the vast preparation made by his father in the study of clinical medicine, which made him one of the most eminent authors of the present age. "The basis of the work is an unbroken series of records of cases in private practice and in hospitals, begun in 1835, and continued for "There is nothing new under the sun.' more than half a century, covering sixteen even Pasteur's theory. It is a well-known fact thousand nine hundred and twenty-two folio that it has long been a custom for a man to pages of manuscript, written with the author's inoculate himself, the first thing upon rising own hand. These records embrace carefully-in the morning, with a thimble full of the dog written histories of cases in all departments of that had bitten him the night before. practical medicine, observed under varied conditions of life, climate, and general surroundings." What a lesson this is of diligence, that one man should have written so many histories with his own hand! We doubt if there is another such example of long persevering toil in our profession. When we learn of this elabor "Not Some one has discovered certain points of similarity between a baby and a widower: He cries a great deal the first three months; after this he becomes quiet, and begins to notice; and it is with considerable difficulty that he is made to survive his second summer.-Texas Courier Record. THE GROPINGS OF MEDICINE.-A physician was once conversing with a prince who spoke of medicine as a science of guess-work. "But, sire," he said, "let us suppose that an Egyptian darkness were suddenly to come over the land. Would you not rather trust to a blind man to guide you to Paris than to one who might see in the light; to one who had learned to grope his way in the darkness than to another who would stumble and go astray the moment his clear sight was dimmed?"-Med. and Surgical Reporter. THE MEDICAL COLLEGE OF THE STATE OF SOUTH CAROLINA IN RUINS.-The following letter to Dr. L. A. Sayre, of this city, will explain itself: "Charleston, S.C., September 11, 1886. Dear Doctor: In the great calamity FAITH HEALING.-Rev. Dr. Buckley, editor which has befallen the people of this city, the of the Methodist Christian Advocate, has a long Medical College of the State of South Carolina article in the June Century opposed to the has been seriously injured—to such an extent claims of Christian "faith healers." "Its that the Faculty have felt constrained to appeal tendency is to produce an effeminate type of to members of the profession to aid them in character which shrinks from any pain, and to repairing the damages. I have been requested concentrate itself upon self and its sensations. by the Faculty to write to you, asking that you It sets up false grounds for determining whether will use your influence among friends to obtain a person is or is not in the favor of God. It any assistance in their power. We hope to opens the door to every superstition. It begin lectures on October 15th, perhaps in a directs attention from the moral and spiritual temporary building. The entire roof of the transformation which Christianity professes to college will have to be reconstructed; the walls work, a transformation which, whenever made, also parted. The contributions to the people manifests its divinity, so that none who behold here have been very generous, but medical it need any other proof that it is of God. It institutions and physicians derive no benefit destroys the ascendency of reason in the soul, from such. You know what peculiar position and thus, like similar delusions, it is self-per- in a community we occupy: every service expetuating; and its natural, and in some minds pected of us, and the most unselfish devotion its irresistible, tendency is to mental derange- to relieving others; while we are supposed to ment."-Albany Medical Annals. be endowed with the faculty of living on air. I need not give you any description of the scenes through which we have passed-the character of which has not been exaggerated in the papers-as these last have furnished the entire country with full particulars. We are still sleeping in a tent in a garden, as women and children complicate the difficulty, and are not readily moved out of the house in case of a shock. These have greatly subsided in force and frequency, and confidence is being fast restored. My house, being of brick, is seriously injured, but habitable. I remain, dear doctor, with best wishes for your health, sincerely yours. F. PEYRE PORCHER, M.D., Professor in Medical College of the State of South Carolina.”—N. Y. Med. Record. THE MALE NIPPLE. During the late war, at a period when the success of the Union cause was pretty well assured, President Lincoln was invited by some distinguished engineers of the army to inspect a plan which had been drawn for a very elaborate and expensive system of defence for the City of Washington. After examining the drawings attentively he inquired what was the necessity for the works. "The defence of the capital," was the reply, "in the contingency of a Confederate invasion." The President thereupon was reminded of a story of a debating society of a Western town, where the question was discussed, "Why does a man have breasts?" THE Canadian Practitioner FORMERLY "THE CANADIAN JOURNAL OF MEDICAL SCIENCE." EDITORS AND PROPRIETORS: A. H. WRIGHT, B.A., M.B., M.R.C.S. England. J. E. GRAHAM, M.D., L.R.O.P. London. W. H. B. AIKINS, M.D., L.R.C.P. London. SUBSCRIPTION, $3 PER ANNUM. Literary Communications may be addressed to any of the Editors. AT All Exchanges and Business Communications should be addressed to DR. ADAM WRIGHT, 20 Gerrard Street East. TORONTO, DECEMBER, 1886. Original Communications. TRACHEOTOMY IN LARYNGEAL DIPHTHERIA. BY DR. L. L. PALMER. (Read before the Toronto Medical Society, I do not intend to discuss the various steps or details in performing tracheotomy, though much is to be said upon these points, and, to my mind, the technique of the operation and subsequent treatment are the most important to discuss, inasmuch as in these we may hope for further improvement, and in this advance hope for greater reduction of mortality, but some of our surgeons seem not so sanguine that the results justify the means. I shall therefore limit my remarks to the necessity of tracheotomy in this fatal disease, though the need of the operation has been hitherto considered established and its position assured, notwithstanding some of our wisest and best surgeons are not so sanguine that the results justify the means. I think, however, that most of our widest differences on this, as well as other subjects, arise more from an indefiniteness in our use of terms and want of clearness in establishing our data, from which we may draw very widely differing conclusions. With a view to arriving at a fuller concensus of opinion on the importance of this operation, and when it is indicated, we will review some of the facts concerning this most fatal disease, and its remedy. With those who object to the operation in toto, I raise issue boldly, inasmuch as I consider the objections, in the face of the light we have lead to bad surgery, and coming from whomsoever they may, will gain the public ear, and foster a prejudice against the procedure, that will render it impossible to get consent for its performance even when most demanded. The already existing dread of the scalpel, plus the objections of a part of the profession, plus the large mortality, even after the operation, make up a sum almost insurmountable by even despairing friends. In all our treatment of laryngeal diphtheria, as in diphtheria in general, and in our hope of successful issue, we must remember that the symptoms are due, (1) In part to a general blood infection, the intensity of whose morbid changes may be so great as to endanger life; and (2) in part to a local specific inflammation, which, because of its perilous situation, may lead on to suspension of a vital function and a fatal issue. Both of these conditions may combine their forces for the destruction of our patient, and either may, independently of the other, be sufficient to do the deadly work. It is perhaps when both these conditions combine, viz., the general blood infection and the local inflammation, that the nicest judgment is required in reference to tracheotomy. For, if after having given relief to all the symptoms of asphyxia by tracheotomy, we still find the patient rapidly sinking by the blood infection or septic poison, we should then see how futile was our effort and conclude our judgment was not well formed. But when either of these conditions is apparently acting alone in destroying the life, the case is compar-erable extent, even in the cases that terminate atively clear. If it is general blood poisoning, operation is fruitless-if laryngeal stenosis, tracheotomy is full of promise. "the object of which is to supply a provisional air passage in the place of the obstructed rima glottidis, so as to keep the patient alive, and to allow the disease to run its course, and gain time for the administration of remedies." Winters. That this end is gained to a consid We, therefore, confine our argument to those cases of laryngeal diphtheria, where the dyspnoea is threatening life, and the blood infection not strongly marked or absent. For the purposes merely of my paper, I will divide laryngeal diphtheria into three varieties. 1st. When it originates in the larynx-true typical croup. 2nd. When it originates in the pharnyx and extends to the larnyx and downwards "descending croup." 3rd. When it originates in the bronchial tubes or trachea and ascends into the larnyx"ascending croup." This latter variety is so infrequent that it may practically be left out of the count. I have never seen a case of this kind, and this is probably the experience of most of those present. Herc, again, I would assume that the symptom and condition present would indicate that opening the trachea would be useless, as the original obstruction and seat of disease lie below the point of operation and, therefore, no relief could be expected. But in the first two varieties the case is quite different, and these are the varieties we meet with, and in the face of which we are called upon to decide for or against tracheotomy. It matters little practically whether it be the first or the second variety. In either case the disease causes death by mechanically obstruct. ing the passage of air into the lungs, and to avert such an issue is the object of our earliest and latest endeavors. Our earliest are spent in topical applications, sprays, steam inhalations, emetics, etc., etc., to detach and expel the obstructing membrane, and if these fail, and they will, as they have done in the past, in 90 per cent. of all cases, and just where they fail, our latest efforts to the rescue lie in tracheotomy, fatally, no one who has observed the results of tracheotomy can possibly question, and I hold it to be a good axiom in this disease, as in many others, "keep your patient alive long enough and he will get well." Tracheotomy, even under most adverse circumstances, does at least prolong the life of the patient by overcoming a positive mechanical obstruction in the larnyx, which is the cause of death in nearly all the fatal cases of croup in which it is resorted to. It saves the patient from death by asphyxia, and will save the life, unless the original gravity of the disease, or some secondary complication intervening, causes a fatal termination. What are some of these complications that so often follow tracheotomy? We may mention (1) Sudden collapse. (2) Cardiac syncope, or (3) Embolism. (4) Persistence and extension of the original disease causing death, (5) by asthenia in some, and by acute nephritis and uræmia in others. (6) Abscess in the mediastinum. (7) Ulceration of trachea from pressure of the tube. These go to swell the number of fatal cases, but none can be truly traced to the operation, except the last, and this should lie within the possibility of prevention. These instead of forming an argument against the operation are evidence of the need of greater care and research as to the details of the operation and subsequent treatment. But another class of secondary complications, (8) the bronchial and broncho-pneumonic are by far the most frequent cause of death after tracheotomy, and this complication is not induced, as has been asserted by some by the operation, but by its having been delayed too long. A few facts are revealed by a long line of autopsies. 1. "That every case of larnygeal diphtheria that died asphyxiated without operation showed extensive bronchial and pneumonic changes. 2. "That those cases operated on that lived from 7 to 20 days showed no such changes. 3. "Cases of pharnygeal diphtheria that died of paralysis or exhaustion rarely showed such changes." From this we may logically conclude that broncho-pneumonic changes are intimately connected with the obstruction in the larnyx to the entrance of air to the lungs. In fact they are related as cause and effect. This is not difficult to see when we remember (as is shown by Dr. Winters) that with the rima glottidis obstructed, and the proper quantity of air, the natural element, not supplied to the lungs, they become less and less expanded, the blood becomes vitiated by imperfect oxygenation, and devitalized and poisoned by the accumulation of carbonic acid gas. In this state of embarrassed and impeded respirations, general venous congestion occurs, the veins of the neck and head become turgid-the entire body cyanosed, and a violent constitutional disturbance is produced, making death imminent. In this state of defective respiration and circulation, and general depression of vital forces, the vessels of the bronchial mucous membrane, and the lungs, become engorged and passively distended. As a consequence of this the parenchyma becomes infiltrated with serum, and the bronchi filled and choked with mucus, and this complication is increased and aggravated the longer the patient continues in this asphyxiated condition. This is withont doubt the condition of every patient that we find in the third stage of asphyxia from diphtheritic larnygitis. Add to this the effects of carbonic acid poisoning from continued non-aerated blood and the shock to all the vital forces from being brought down so near to death, and the gravity of the case must be appalling, and yet 9 out of 10 of our tracheotomies are under such unfavorable conditions. We are advised to delay operation until the patient has the glare of death clearly marked, and if the broncho-pneumonic complications, which, at this last stage, are already of an alarming character, are not cleared up by opening the windpipe, as is sometimes the result of this procedure, the operation is charged with having excited this disease, whereas tracheotomy is as clearly indicated to relieve this state of venous congestion of the lungs, as it is to relieve the asphyxia. Now, if this pulmonary and bronchial congestion is largely due to the obstruction in the larnyx, and the consequent defective oxygenation of the blood, then it is apparent that the early introduction of the canula into the trachea, and the full and free introduction of pure air into the lungs removes at once a fruitful cause of engorgment, stasis, and consequent exudation and infiltration into the bronchi and parenchyma of the lungs, and offers the speediest and best remedy for that which may have already taken place. "It is certain," says McKenzie, "that the early introduction of the canula offers the patient a much better chance of recovery than when there is long delay, and it is owing to the disregard of this fact that tracheotomy in diphtheria has in some quarters acquired such an evil repute." But it is urged by some, and among those I observe Dr. Bell, in his paper before the Canada Medical Association : seems to "The re 1. That if patients are operated on early many would be operated on unnecessarily. 2. Extension of membrane took place more rapidly after operation. Neither of these propositions is supported by clinical facts, as Dr. Bell show in his next words, viz. : coveries after early operations were 25 to 33 per cent.; after late operations, 5 to 10 per cent." Now, I understand it to be an accepted clinical fact that of these cases of diphtheritic larnygitis, only 10 per cent. recover, 90 per cent. die without operation. If only 10 per cent. of these cases without operation recover, 5 to 10 per cent. after late operation, and after early tracheotomy, 25 to 33 per cent. recover, this certainly convinces me that early operation offers the patient a better chance of recovery than a late operation, or than no operation at all, by about 23 per cent. In the hospitals of London, Paris, and Berlin, the operations are advised early and are generally performed by the house surgeon, so as to allow no delay, after the symptoms demand it, and the result has given about 33 per cent. of recoveries. In the Boston City Hospital during the last 20 years, about one-third of the cases operated on have recovered, and every one of those that |