tack of the enemy at "night's mid-most stillest hour," leaving his arms and ammunition in his tent. The dumb doctor, like the silly soldier, is often doomed to defeat. Forewarned, well armed.

The self-administration of drugs at the hands of the physician to a patient in dire distress, outside of the question of time saving, has a psychical effect, for who has not seen the anxious expression on the face of the sufferer who, with good reason, fears that all may be over before the messenger returns from the pharmacy. In case both the physician and his prescription leave, it seems to the sufferer that all hope has departed. Self-administered, the physician is assured that the patient has the remedy properly given and has time to wait and observe its mode of action.

Non repetatur has little effect on the ordinary druggist, and all habit-forming drugs, narcotics, and such were better dispensed than prescribed, as they are then under the control of the physician. He would be able to follow the patient and know how often he was repeating the prescription and, in his judgment, allow or restrict its continued use.

Pecuniarily speaking, there are remedies which should be kept on hand. Those drugs and combinations which are in everyday use and which keep well.

Pills, tablets, or ready-made mixtures. are not the only remedies which can be kept on hand by the busy practitioner. While these are most convenient, yet many useful combinations may be readily made with the aid of a few active principles, tinctures, and fluid extracts.

The confidant and friend of him who, in distress, confides to us not only his sufferings, his sorrows, but also his shame, we should administer ourselves, where practicable, the remedies which become necessary in these cases. If they went to a drug store they would divulge to the drug clerk and his many chums the nature of the malady for which your patient was, in all confidence, consulting you alone, Emmenagogues are sometimes properly advisable, yet what drug clerk and the numerous young men loafers who are in his confidence will not surmise the worst, with reference to both patient and physician, when a lady patient hands him a prescription for these drugs. Syphilis and gonor

rhea should be treated, in the majority of cases, without the aid of the druggist. The latter treats numbers of these cases without the aid of the physician. They should be kept in close confidence, and a drug store is, in the great majority of cases, not a secret service bureau. Aside from this there is the danger of the patient repeating the prescription indefinitely, thus injuring both himself and his medical attendant. The various remedies for the treatment of these confidential cases and their sequelæ should be kept on hand by the general practitioner.

A hypodermic syringe, a good one, of simple construction, which will not get out of order, should, like the doctor's nerve, be always with him even in his dress suit. It should be omitted only in his bathingsuit, and then should be on the beach. His hypodermic case should contain soluble hypodermic tablets of morphine, morphine and atropine, codeine, apomorphine, atropine, strychnine, nitroglycerin, morphine and hyoscine, pilocarpine, cocaine. These remedies may, of course, when necessary, be used by the mouth as well as hypodermically.

We have long been in need of a remedy which, given hypodermically, would cause a prompt evacuation of the bowels. This we seem to have in apomorphine hydrochloride. Diphtheria and croup demand quick action and a package of at least 3000 units of antitoxin should be at hand and changed as necessary. It is wasted time to telegraph and take the train for antitoxin after a case of diphtheria is discovered. Calx iodata and other remedies for croup should be ready when needed.

The obstetric bag should contain chloroform, ether, phenol, boracic acid, ergot, bichloride of mercury tablets, sealed tubes of aseptic ergot, quinine sulphate, petrolatum, adhesive plaster, absorbent cotton, and sterilized gauze.

Urinalysis.-Nitric, sulphuric, tartaric, citric and hydrochloric acids, Fehling's solution, liquor potassi, hydroxide, and bismuth.

Poison Antidotes.-Lime water, carbonate of magnesia, vinum ipecac, olive oil, zinc sulphate, peroxide of iron, charcoal, ammonia, alcohol, vinegar, atropine.

A medicine case, which constantly ac

companies the writer, contains: Tablets or pills of calomel and soda, acetanilid and codea compound, migraine, mercury protiodide, mentholic throat lozenges, chlorate of potash and borax, cocaine tablets for solutions, caricans comp., calcidin, methylene-blue comp., coryza, iron, arsenic and strychnine, orthoform lozenges, nitrate of amyl in pearls, Seiler's tablets, aloin, strychnine and belladonnæ comp., soda mint, Dover's powder, heart stimulant, vaginal astringent, quinine, triple arsenites with nuclein, bichloride antiseptic tablets, morphine, glonoin, while in screw-capped bottles in my bag are phenol liquefactum, spiritus frumentum, hydrogen peroxide, aromatic spirits of ammonia, chloroform, chloral, solution of protargol, vaccine points, slides, sputum bottles and swabs for specimens for microscopical examination, tube of ethyl chloride. This, of course, varies somewhat as to the time of the year and the diseases then in mode. There are, of course, a number of other solutions and drugs and appurtenances which one should have about the office, but are too bulky to carry about and too numerous to mention. They will accumulate if you practice long enough.

Some of these remedies, if at hand at the right time under urgent circumstances, are worth their weight in gold, and the practitioner who has them not when sorely needed, feels correspondingly cheap.

The general practitioner should neither dispense nor prescribe exclusively, but adhere to the happy medium, doing a part of each as best for himself and his patient.

19 West 7th St., Cincinnati, Ohio.

SOME EXPERIENCES WITH PUERPERAL ECLAMPSIA.

BY J. H. HIDEN, M. D.

In discussing puerperal eclampsia, I am well aware that nothing really new is presented in this article. It is simply my purpose to review and to emphasize the value of certain medical facts as they appear to me in the management of such cases. When called to a case of puerperal convulsions we then have little or no time for meditative work. The time for action has

come.

The physician should be cool, well informed, and more or less decided in his course. The general condition and symptoms of his patient should suffice to suggest an appropriate modification of any preconceived and favored plan of treatment. Thomas Macaulay, in his brilliant essay upon Sir James McIntosh, calls the readers' attention to the fact that it was seldom possible to get an opinion from Sir James in its formatative state. The opinion was almost invariably ready, based upon carefully selected evidence, and formed in the most accurate, elegant language. In other words, he had his knowledge and opinions at his command. It is not requiring too much to expect at least an approximate degree of such proficiency from the physician.

Many theories have been advanced about the etiology of puerperal eclampsia, some of which have often confused, rather than enlightened, the general practitioner. Here we find the old rule observed, namely, that the less we know of a subject the more eloquently we can write, for then, you know, there is no end to speculation. Among the theories advanced as to the cause or factors in the etiology of puerperal eclampsia we have, in a nutshell, as follows: Mechanical pressure from the gravid uterus; fetal products of excrementitious matter; toxic products and biliary salts of fetal origin; increased metabolism; uremia; toxemia; leucomaines in the blood; ptomaines in the circulation; impaired functions of the glandular organs; hepatic cellular degeneration; faulty action of the hepatic functions in the processes of metabolism; renal insufficiency; renal congestion; nephritis; more or less sensitive condition of the motor areas of the cerebrum, etc. At present the consensus of opinion is, however, that the most constant and predominating factor in the etiology of puerperal eclampsia is renal insufficiency. The primary cause in most cases, then, may be considered a toxemia. This thought, accepted and digested, will doubtless point out to the physician a rational course of treatment. And though in some cases this toxemia may be more or less of hepatic origin, as has been often. shown upon autopsies in which fatty, cellular degeneration, capillary hemorrhages, infarcts, etc., have been observed, yet the

general line of treatment should be practically the same, namely, to control convulsions and hasten the work of elimination. Now, in viewing puerperal eclampsia as the outcome of a toxemia, it is well to note that many of these cases of toxemia do not develop into convulsions at all, just as delirium is not always produced by the same degree of pyrexia even in the same patient. In other words, there are various kinds and degrees of puerperal toxemia which may, or may not, produce convulsions according to the conditions in each given case. I have seen in my own practice uremic coma develop instead of convulsions. This form of puerperal uremia is to be the most dreaded, as it is likely to prove apoplectic in character. I am glad to say I have had but one of such a type in my practice. In this case early forceps delivery, venesection, etc., proved fruitless. Up until this time I had followed in all cases of puerperal eclampsia venesection as the "life-saving agent." And, though yet a believer in the value of venesection in properly selected cases, yet of late years I have omitted this means of controlling convulsions with the most gratifying results. Indeed, I have treated seven successive cases, several of which appeared almost hopeless, with no mortality. Three of these were in persistent coma from eighteen to thirty-six hours during the intervals of violent convulsions. Two of the seven (primiparæ) were operative cases under complete anesthesia, in one of which was required a high-forceps delivery. In this latter case (the only one of the seven in which I had a consultant) convulsions persisted even when the pulse had been reduced to fifty beats to the minute. My consultant, regarding the case practically hopeless, retired, leaving me to deliver her without medical aid. Following her delivery, cathartics (croton oil, calomel, jalap, Epsom salts) and diuretics (bitartrate of potassium and benzoate of sodium) were freely used. Saline enemas and the hot, wet pack were also employed until consciousness was restored and convalescence established.

Now a little more about treatment. Morphine and veratrum viride were used instead of venesection. The first dose of each is given together hypodermically (morphine, gr. %, and tincture of vira

trium, 12 gtts). If this does not materially reduce the pulse-rate within twenty or thirty minutes, a second dose of about half the quantity is given. If additional doses are still needed, they are given by mouth. As soon as the pulse-rate is reduced to about sixty beats to the minute, a mixture containing chloral hydrate, bromide of potash, and veratrum is prepared to be given at stated intervals (say, every two hours) in sufficient doses to keep the pulse-rate within safe bounds, and furnish to the motor areas a nerve sedative.

The next feature to be considered in the treatment of eclampsia is that of elimination. To this end two drops of croton oil, with three grains each of calomel and jalap, are put upon the back of the tongue, and teaspoonful doses of Epsom salts are given every hour or two until free catharsis is accomplished. An enema of a normal salt solution is also often helpful. In some cases the normal salt solution may be given subcutaneously with advantage.

Diuretics, as bitartrate of potassium, benzoate of sodium, should also be added at stated intervals. Later on, after delivery is accomplished and convulsions have subsided, if the pulse should become weak, the diuretics then should be exchanged for others of a more stimulating character (digitalis, strophanthus, etc.). Moreover,

at any time during the course of treatment, if patient's condition appears critical, the hot, wet pack must not be forgotten. Out of my seven cases above referred to, the most desperate were put in the hot pack with excellent results. My last case, after having had nineteen convulsions, was put in a hot pack and kept there for three hours, and the process was repeated at stated intervals until complete consciousness was restored and convalescence established.

In conclusion, I may add, by combining such drugs as morphine and veratrum in their proper proportions we avoid, in a measure, the great danger of over-dosing with either drug. The same is true in regard to the second combination containing the chloral mixture. And when the hot pack is employed a still greater diminution in these drugs can be allowed with a more or less proportionate degree of safety.

Pungoteague, Va.

MEDICAL LITERATURE

SO-CALLED.

BY CHAS. S. MOODY, M. D.

I may be very easily wearied, but there are some things in the current medical publications that are inclined to produce in me that "tired feeling" we read so much about. With a very few exceptions-I can point them out if you wish me to-the medical publications are stuffed full of "papers" read by some ambitious medic at the County Medical Society meeting held in Podunk Corners. Now, I haven't the slightest objections to John Henry Smith, A. M., M. D., impressing the assembled representatives of the healing art from the back districts with his wonderful erudition, but I do register a kick against the editors of journals that we pay our good money for, aiding and abetting the said John Henry in his nefarious attempt at impressing us with his superior knowledge. These days it seems the proper thing for county medical societies to invite some professional "lion" to address them upon some important topic. The greater the "lion" the better they like it. The lion comes, shedding an air of importance, like an aura about him. He arises and pompously details some professional hodgepodge that is the same old story in a new laid gown, while the bucolic medics sit with mouths ajar and drink in the words of wisdom as though they were pure from the Pierian spring. The "lion" does not say so, of course, for that would be telling, but the inference very strongly is that all the brethren from the wood's pasture should send to him all such cases as come under the head of the particular paper he reads. They do it, too. They remark unto themselves, "What wisdom! What knowledge. How can one head contain it all?” In fact, the whole screed is nothing but a rehash, and generally a very poor one, of some chapter on the subject taken from one of the standard authorities, and not one of the "lion's" auditors but could produce a better one with both hands tied.

One great trouble with the human family is that they are lacking in the sense of humor; they are inclined-especially doctors to accept the blatant assurance of

some designing demagogue as revealed. truth. The average medic is too blamed busy to either make money or analyze what he hears or reads. That's one thing that kept the medical profession back about a thousand years. Some ancient disciple got in the habit of harking back to the Dark Ages for his medical wisdom, and he transmitted the habit to his successor, and before we knew it the thing got to be hereditary, so by the advent of our day we cheerfully accept canned religion, politics, music, medicine. The ministerial profession are ahead of us in one thing; the preacher knows that his congregation will accept as words of great wisdom the simplest statement if he only utters it solemnly enough. We fellows of the scalpel and pill bags do the same thing, but we don't know it. Let some chap with a local fame in the nearest overgrown town come out to your county meeting and tell you that "the square erected on the hypotenuse of a right triangle is equal to the squares of both its other sides," and if he says it earnestly enough you will nearly faint with wonder at his learning.

I object. I don't suppose it will do any great amount of good, but I object anyway. I register my plaint for the hardworked country doctor who knows more medicine in a day than these sprigs of medical nobility will ever learn, and who is so impressed by the glamor that surrounds one of these that he is happy to sit and listen to the droning over of something that he knows better than his self-elected instructor. I am for medical societies where the brethren meet upon a common level and relate to each other their successes and failures. I am for medical soIcieties where the members may listen to practical papers by practical men upon every day subjects, such papers written, not for the purposes of advertisement and subsequent publication, but from a desire to do good. I don't give a rap whether the author murders the English grammar or not. If the paper is stuffed full of good things I can overlook the literary imperfections. I can cheerfully hit any grammatical error that I happen to see riding along on the train of an idea and knock him into the middle of next week, then appropriate the idea for my own consumption.

Now, let me take an easy fall out of the medicals journals. About all the alleged important (?) journals find their way onto our table. About all the journals that are satisfied to occupy a lower niche in the wall also drift in. The wrappers get removed from practically all of them. A few of them are read and filed. The big journals-those with a name-prove the least interesting of all. Why is this? The reason is not far to seek. They, like the County Medical Society of Posey County meeting at Podunk Corners, have gone "lion" hunting. Their columns are filled with alleged wisdom in the shape of professional "papers" upon unprofessional subjects. The average practitioner vainly chews around over all the mess of verbiage in the forlorn hope of extracting something that he can use in his work. Not a glimmering of a thought, not an idea that rises above the dead level of the commonplace. As Holmes remarked of the katydid, "Thou sayest an undisputed thing in such a solemn way." They prattle along for several closely printed columns iterating and reiterating things that have been told in books since Aesculapius was in swaddling clothes. Then the whole miserable mess is dignified by the ultra scientific journals as pure unadulterated science.

As an illustration, people understand better if things are mapped out for them. Several years ago I read in one of the great scientific (?) medical weeklies an article by some would-be surgeon just across the line, not so blamed far away but his name is pretty well known in your Uncle Sam's domains, however. This is what he advocated as a substitute for ventro-fixation of the uterus. Listen closely: He placed the victim (that's the only name for her) in the Sims's position and exposed the cervix uteri. Grasping the anterior lip of the cervix with a volsella, his assistant put the cul-de-sac of Douglas on the stretch. With a long, curved needle designed especially for that purpose, loaded with heavy catgut, the surgeon then passed it up through the cul-de-sac around the fundus, carrying the ligature into the fundus near the top and bringing it out through the abdominal wall. Unthreading his needle and threading it upon the opposite end of the suture, he repeated the performance. Grasping the two abdominal

ends he made traction until the uterus was well up against the wall; then the sutures were firmly tied and the victim placed in bed. The author did not proceed to tell us how soon she was placed in the casket, and was equally negligent about informing us regarding the details of the funeral. I wonder what sort of monuments they erect to their dead in Canada? O tempora! O mores! O mamma!

Now, my good country cousin (I'm one of you myself, by the way) what do you think of shucking out your good hard dollars for such medical "hog wash" as that? That was only an isolated instance. I can find you plenty more of them if you care to see them. The chances are that thousands of physicians read that thing and set the author down as a man of original ideas, and they were correct, too. Nine physicians out of every ten would read that thing, and if they were not doing a lot of surgery, or seeing a lot of it done, would pass it by without analysis. It's the tenth man that reads the ridiculous in these articles and "cusses" himself for throwing away his good money.

For practical considerations, a three-fold division of this paper was deemed justifiable.

The first part will be devoted to a consideration of the subject as a whole; the second part includes an analysis of all the cases of uterine perforation consecutive to intra-uterine maneuvers, published in the English, French, and German medical literatures from 1895 to 1907 inclusive; the third will embody what my clinical experience leads me to consider safe, conservative, and practical suggestions and conclusions.

Practitioners must not be unmindful of