nates more rapidly and perfectly effete materials from the system, thus aiding the kidneys when they are temporarily unable to perform their functions perfectly, or are organically diseased; is an excellent means for mental and physical diversion; causes many indolent persons and those who lead sedentary lives to exercise more freely, being pleasurable and easy to take after mastering the machine; is one of our best simple measures in the treatment of cases of insomnia, and, last but not least, is an agent in the moral culture of individuals in pleasurably diverting their minds and meeting their demands for occupation, thus answering the place of saloons, beer-gardens, and other similar places, where companionship is sought.

CASE REPORT OF FIBROID TUMOR OF THE UTERUS WITH SUPPURATING OVARY DISCHARGING PER RECTUM.1

BY RUFUS B. HALL, M.D.,

CINCINNATI, O.,

PROFESSOR OF CLINICAL GYNECOLOGY AT THE MIAMI MEDICAL COLLEGE; GYNECOLOGIST AT THE PRESBYTERIAN HOSPITAL; FELLOW OF THE AMERICAN ASSOCIATION OF OBSTETRICIANS AND GYNECOLOGISTS; OF THE SOUTHERN SURGICAL AND GYNECOLOGICAL ASSOCIATION, AND THE BRITISH GYNECOLOGICAL ASSOCIATION,

MR. PRESIDENT AND GENTLEMEN: The subject of operative treatment for fibroid tumors of the uterus is one in which the keenest interest is manifested by men engaged in abdominal surgery. The main points in the technique of the operation have been practically settled, but certain minor details in operative procedure are capable of improvement. The greatest difficulty is to successfully overcome certain complications and obstacles occasionally arising, which tax to the utmost the skill of the operator.

The following case, which I shall report somewhat in detail, illustrates a number of these complications, and will serve as a basis for a few remarks to be made later.

Mrs. J. W, aged forty-four, married sixteen years, mother of five children, the youngest six years of age, was referred by Dr. Heady, of Glendale, O. She always enjoyed good health until about five years ago, at which time she observed that the menstrual period was prolonged and somewhat excessive. As time passed on she noticed that this symptom grew worse, and within a year or two was added pain in the back and a heavy bearing-down sensation in the pelvis during and for a few days following the menstrual period. She did not apply to a physician for relief, however, until some time in February of the present year, when the diagnosis of fibroid tumor of the uterus was made, and the usual treatment followed by the general practitioner suggested. This had little effect, either for relief of the hemorrhage or of the pain, which had become quite severe, especially in the right side of the pelvis and abdomen.

She gradually grew worse until the latter part of April, when she was confined to bed with an attack of general peritonitis. She was very ill and had a high temperature and rapid pulse for two weeks. She then had a discharge of several ounces of pus per rectum, which relieved her somewhat of the pain, and the temperature dropped for a few days. Her general symptoms were not at all improved, but were really aggravated. The temperature chart and her general condition showed her to be suffering from sepsis. There were soon added diarrhoea, chills, and sweats. In the course of eight or ten days she again had a discharge of several ounces of pus per rectum, and was again temporarily relieved. This periodical discharge of bad-smelling pus continued at irregular intervals up to the time she entered the Presbyterian 1 A paper read at the Southern Surgical and Gynecological Association, Charleston, S. C., November 13, 14, and 15, 1894.

Hospital in my service, June 2, 1894, when the case was first seen by me.

The patient was fairly well nourished; pulse, 140; temperature, 103. She was unable to walk or sit up, and had to be carried into the institution. She was having diarrhoea, irregular chills, and profuse sweats, which she said had been of almost daily occurrence since the abscess first discharged. There were intervals of eight or ten days in which there was no discharge of pus; the diarrhoea and sweats were always worse at that time. The patient said there had been no discharge for more than a week before she entered the hospital, and expressed a wish that it would soon discharge again so that she might have relief.

Examination revealed a hard round tumor in the abdomen, apparently the size of a cocoanut, extending some four or five inches above the symphisis pubis, and slightly to the left side. By combined examination, this tumor was diagnosed as the fibroid uterus. Behind and to the right of the tumor, filling up the pelvic cavity and projecting well toward the perineum, was an elastic tumor somewhat larger than the fibroid just described. This latter I believed to be a suppurating ovary, and from the clinical history had every reason to believe there was a communication with the bowel through which it emptied out a small part of its fluid contents.

The patient was in such a wretched condition to be subjected to a section that an operation seemed to promise but very little. Her friends and physician, who had assumed charge of the case but a day or two before she entered the hospital, were very anxious for the operation, knowing full well that without it she had absolutely no chance for recovery. She was able to take but little nourishment, and that of the blandest character, owing to the irritability of the stomach.

On June 6th the operation was made and the tumor removed. I here present it for your inspection, as it will aid very materially in the explanations to follow. You will observe that the solid part of this tumor is the fibroid uterus, including the neck and cervix. As is my custom in these cases, I made total extirpation. At the side of this tumor there is a sac which represents the suppurating ovary; it is densely adherent to the fibroid uterus. You will see on the lower part of the sac an irregular opening through which you can introduce the thumb. This is the site of communication with the bowel, and will be described later. The opening into the sac near the fundus of the uterus is the point of rupture of the sac during extirpation, after the occurrence of which it was hastily torn open so as to facilitate washing it out before enucleation. The fibroid tumor rode up out of the pelvis proper and rested upon the sac of the suppurating ovary, which practically filled the pelvic cavity and was universally adherent. The omentum and intestine were adherent over the top of the tumor, closing in every portion of it, as you will observe upon careful examination of the specimen. The adhesions were overcome with considerable difficulty. They were all separated down to near the point of attachment to the bowel at the point of communication. When we neared that point, we separated as much as possible of the capsule of the suppurating ovary around the opening, leaving several tags of the capsule attached to the bowel, hoping that thus we might separate the sac from the bowel without making a communication with it, there having been no discharge of pus from the bowel for ten or eleven days. In this, however, we were disappointed, for when we had enucleated the sac, we could pass two fingers into a rent in the bowel, which proved to be the rectum just below the promontory of the sacrum. A resection or Murphy button was out of the question. The opening was immediately plugged with gauze and the operation of total extirpation proceeded with.

When we had completed total extirpation, we could say with all candor that nothing in the pelvis remained

which had the least resemblance to peritoneum. For that reason no attempt was made to close the vagina from the peritoneal cavity with stitches, as is my custom, but the vagina was packed with gauze and our attention turned to the repair of the hole in the rectum. This opening crossed the rectum diagonally, and by experimenting we found we could bring the edges together without materially lessening the calibre of the rectum. With a fine suture of catgut, a running stitch was made of the mucous membrane only. After this the muscular coat was brought together with interrupted silk sutures, and on top of this, one of the tags which had been peeled from the outside of the cyst wall, and which was still adherent to the bowel near the opening, was turned over the row of stitches and united around its free margin with twelve or fifteen interrupted silk sutures. The cavity was thoroughly irrigated, the pelvis packed with gauze, and the wound closed. Before the patient was put to bed, the sphincter ani muscle was thoroughly dilated.

The operation consumed one hour and five minutes time. The patient was put to bed in profound collapse, but she rallied within a few hours and appeared to be none the worse for the severe ordeal through which she had passed. The gauze in the pelvis was removed through the abdominal incision on the fourth day, and the pelvic cavity washed out with peroxide of hydrogen, there being a free outlet through the vagina. This washing out process was repeated every four to six hours for ten or twelve days. There was never the least indication of leakage through the bowel injury.

For nearly three weeks the high temperature, rapid pulse, and sweats continued, though not so severe as before the operation. At the end of that time her temperature became normal and she improved rapidly. She left the hospital the middle of the fifth week, thoroughly convalescent, and is now perfectly well.

There are a number of questions of operative procedure suggested by this case, to which I wish to direct attention. Whether or not to advise an operation upon a patient suffering from prolonged and profound sepsis, during the attack, or wait with the hope of putting the patient in a better physical condition, is a question that must be decided on the merits of each individual case. It is a question that admits of discussion both pro and con. There are good grounds for basing an argument on either side, but there are cases where there is nothing left to do that promises any chance of saving life except the radical operation.

The technique of the operation for fibroid tumor associated with a large suppurating ovary, is an interesting study. If with extensive raw surfaces in the pelvic cavity which have been thoroughly bathed in pus during the operation, and no peritoneum to close off these raw surfaces from the general peritoneal cavity, we use the Baer method, which does not give thorough drainage, I do not believe we will have such satisfactory results. I think total extirpation of the cervix, leaving free communication into the vagina for subsequent drainage, gives the ideal condition, both theoretically and practically, for after-treatment in this class of cases. unhesitatingly recommend it.

I can

In

The separation of the firm adhesions of the bowel in the pelvic cavity should be done with the utmost care, for even then a bowel injury is not uncommon. cases where there has existed communication for several weeks or months, we necessarily have a bowel rent in a very unsatisfactory condition for repair. If there is no peritoneum to be recognized as such for some inches from the injury, and a resection or Murphy button is out of the question, the strengthening of the suture line with a tag of adventitious tissue, as described in the operation, is very desirable. It is a method I have employed on several occasions with perfect results.

Packing the pelvic cavity with gauze, thus keeping the healthy intestine away from the raw surfaces in the

pelvis, and protecting the general peritoneal cavity from intestinal leakage, if any should occur, preventing intestinal adhesions there, is a step in advance in the treatment of these cases and one to be commended. It cannot be fully appreciated by those who have not employed it. I usually remove the gauze in the pelvis on the fourth day and wash out the cavity with peroxide of hydrogen, repeating this washing out four or five times daily as long as necessary.

Again, forcible dilatation of the sphincter ani muscle before putting the patient to bed, adds greatly to the chances for recovery. It causes incontinence, thus relieving the intra-intestinal pressure from accumulating gases. All of us who have had experience in abdominal work, know that the sphincter muscle in these cases contracts to such a marked degree that the large bowel frequently becomes enormously distended with gas; and if there is a rent, it puts undue pressure on the weak point, thus favoring intestinal leakage into the peritoneal cavity. So far as I know, I was the first man to practise forcible dilatation for this purpose. The first time I employed it was February 6, 1893, in a case of extensive bowel injury, in a patient operated upon for extrauterine pregnancy. The patient recovered.

CONTREXEVILLE.

BY DEBOUT D'ESTRÉES, M.D.,

PARIS, FRANCE.

A KNOWLEDGE of the virtues of Contrexeville, the springs of which were till then only visited by the inhabitants of the neighboring villages, dates from the lecture read before the Société des Sciences et Arts of Nancy, January 10, 1760, by Dr. Bagard, first physician to King Stanislas, of Lorraine, to whom we are indebted for the following passage:

"The mineral waters of Contrexeville are a sovereign remedy in diseases of the kidneys, of the ureter, of the bladder, and the urethra, stone, gravel, glaires, suppuration. We can assert that these waters are efficacious against the stone, which they loosen and drive out of the bladder, when the stone is not of a considerable size; that they dissolve and break larger stones when the latter are chalky. We keep a list of patients of all ages who during several years have got rid of stones through the effect of these waters. They prevent fresh attacks of gout, by restoring the suppleness of the nerves and of the membranous parts which the disease has dried up. As these waters contain ferruginous matter, a mineral acid, and soap, they will be very useful in cases where the bile becomes too thick and where the liver is obstructed, the more so as these waters are purgative."

This quotation gives, in the medical style of the period, a very exact idea of the properties of the waters of Contrexeville, which it exaggerates in nothing. And from this time foreign invalids began to make use of them.

Many very celebrated cures are still authentic, and among others that of the Abbé de Bouville, who, after having been three times operated on for stone found relief for his pains at this spring, and was enabled to finish his career, which was prolonged for many years, without again having to undergo an operation.

Effects quite as remarkable, observed in the persons of many noblemen of Lorraine and its environs, began to make a great reputation for the waters.

From 1775 to 1789, thanks to the renown and merit of Thouvenel, physician to the Court at Versailles, who was loud in the praise of the waters, the village of Contrexeville saw princes and gentlemen thronging to its establishment. These personages, in their moments of leisure, amused themselves playing tragedies and comedies in the pretty little theatre built by the Princed'Hennin at his own expense.

The English visitors at Contrexeville built, in the year 1783, a mansion known as the Château des Anglais," which is now only inhabited by some of the poor workmen of the place.

One can easily understand, after what I have just said, the terrible shock the Revolution of 1789 must have been to the fortunes of Contrexeville, which the minister Necker wanted to buy for the state. Emigration deprived the village of the yearly presence of its noble visitors, and as long as the troubles of the Revolution lasted the station was almost deserted.

At the time of the Restoration a late surgeon of the Imperial army, Mamelet, came and settled at Contrexeville to practise medicine. He had occasion to meet there Dr. Thouvenel, who made known to him the properties of the spring of mineral waters. In 1825 Mamelet, who had conscientiously studied the effects of these waters, published a work, which made such a sensation that from that time forward they took an important place in therapeutics. M. le Dr. Civiale, wrote, in 1828 "It seems evident to me that these waters possess the property of strongly exciting the urinary organs, and that this property renders them useful for determining the expulsion of large gravel, at the same time that they lead to a surer diagnosis of stone in the bladder, a question which is of more importance than one thinks."

Between 1825 and 1844 Mamelet published a second, and then a third edition of his work. Nevertheless, the affluence, so considerable to-day, was slow to establish itself at Contrexeville, in spite of the incontestable merits of this station.

M. le Dr. Peshier, member of the Academy of Medicine of Paris, in his report on Mineral Waters (March, 1853), thus explains the reasons of this: "While our numerous thermal establishments, so various, but all animated with a desire to make a noise in the world, sounded their own praises in advertisements as well as by the results of study and scientific discussion, Contrexeville alone, scarcely drawn out of its obscurity by the conscientious, though not well-known works of Bagård and of Thouvenel, waited in silence for the gratitude of its clients to lead medical opinion to determine its precise value. Innocent of all surprise of stimulating general opinion, disdaining a precocious discovery which might end in myth, this bountiful. spring, by the simple fact of the multiplicity and the constancy of the cures, which were made known all over the world, arrived at such a point of notoriety that its name is not less identified with the idea of gravel than that of sulphate of quinine is with the idea of intermittent fever. This justice is rendered to it everywhere and without contest."

Contrexeville is situated in the Vosges, in a valley open from south to north. One meets in every part of this valley, at a depth of about three yards, a layer of green clay about a yard thick, through which the spring "Pavillon" has made its passage.

The cistern for arresting the water which penetrates this green clay isolates the spring from rain-water, which circulates in the calcareous beds above this layer of clay, and thus permits the water to arrive free of any admixture to the surface.

Source du Pavillon.-This water is cold and limpid; its temperature is invariably 11.5° Centigrade. Its specific gravity does not exceed 1.025. It has a slight ferruginous taste and is very refreshing. It produces scarcely any effect on litmus paper, but it gives a greenish color to sirup of violets. When exposed to the open air, it is soon covered with an iridescent film, which disappears when the water is shaken.

The

stone reservoir into which it falls, the pipes through which it passes, whatever is thrown into it, are rapidly covered with a yellowish coating resembling rust, which is composed of carbonate of iron mixed with carbonate of lime.

The principal minerals the water contains are, ac

cording to the analysis made in 1864 by M. Debray, sulphates of lime and of magnesia, bicarbonates of lime and of magnesia, of iron and of lithium, to which we must add traces of fluoride and of arsenic.

It is, therefore, above all, a water having a foundation of lime with lithium, to which iron and arsenic add their reconstituting qualities, so precious for our anæmic generation. This spring is also slightly laxative. These properties render it useful for patients whose sluggish intestines have to be stimulated.

Manner of Employing the Waters. It is evidently to the ingestion of the water that the good results obtained at Contrexeville are due. Taken fasting, a glass at a time at intervals of ten, fifteen, twenty, or thirty minutes, it produces on the human economy effects which we shall describe further on. It is, to quote Dr. Patissier, "so friendly to the stomach" that it can be taken in relatively large doses. These doses must, nevertheless, be regulated by a medical man, according to the age, the sex, and the disease of the drinker.

A robust man suffering from gravel, a debilitated gouty patient, a woman suffering from hepatic colic, an old man suffering from catarrh of the bladder, would each require a different and special treatment.

In most cases the results obtained by treatment at the spring itself, are confirmed by the use of the water at home. Its effects, inferior to those at the spring, are, nevertheless, easy to prove by those who have used them, especially in cases of chronic affection of the bladder.

It is important, however, that the water should be drunk, as a rule, fasting or during the intervals between meals. Finally, although we have known a case where satisfactory results were obtained with water which had been bottled for seven years, we recommend patients to procure for themselves the water, as fresh as possible, by applying either to the establishment at Contrexeville, Vosges, or to any mineral-water dealer in the United States.

Physiological Effects.-The waters of Contrexeville stimulate all the secretions, but they especially help that of urine. In the digestive organs this stimulation is at once observed to act upon the stomach by increasing the appetite and regulating the functions of the digestive organs. This is especially remarkable in patients suffering from those dyspeptic ailments, which so often precede the appearance of the uric acid diathesis.

The waters are also observed to act on the intestines by producing a laxative effect, shown by two or three liquid stools, which does not in any way fatigue the patient.

In the circulatory system the stimulation of the waters often causes a kind of inebriation of the patient, which always disappears after the first meal. The functions of the skin are restored by the influence of the hydro-mineral treatment when they have been suppressed. According to Dr. Baud, the genital organs of men are also stimulated by the use of the waters of the Pavillon. On women suffering from gout or gravel, it tends to the regulation of the menses, and thus has rendered fruitful gouty women who until then had

been barren.

But it is upon the urinary system that the principal physiological effects are produced by the waters of Contrexeville. They produce considerable diuresis, and the quantity of liquid voided is always greater than the amount of water which has been absorbed. They modify the mucous membrane of the urinary tract, and the remarkable results in catarrh of the bladder are due to this effect. They stimulate atony of the bladder. They drive away the pains caused by gravel in the kidneys, as can be seen every day at the spring of the Pavillon, and they expel the excess of uric acid from the system. Finally, they often reveal the presence of large calculi, unsuspected till then, and the size of which will not permit them to pass through

the natural channels.

The diseases treated at Contrexeville, are, in the order of their frequency, as follows: Gravel, gout, diseases of the bladder and of the prostate, diabetes, and hepatic colic.

Gravel.-The effects obtained at Contrexeville in cases of gravel are too universally known for it to be necessary for me to dwell long on this subject; the brilliant results which caused it to be said that Contrexeville was for gravel what sulphate of quinine was for intermittent fever, would be still more remarkable if all the gravel patients would keep the health rules so strongly recommended to them when they leave Con

trexeville.

Unfortunately, a great number of them break out into excess by either indulging in a too rich diet or by leading a too sedentary or too busy life, and the same causes bring back the same effects, and they are obliged to come to the spring of the Pavillon to be able to indulge again in excesses.

This applies specially to uric acid gravel (red gravel). M. Durand-Fardel, inspector of the springs of Hauterive at Vichy, whose works on mineral waters and on chronic diseases have a legitimate authority, classes, in the following manner, the use of the waters of Contrexeville, for this kind of gravel:

"In cases of renal pains, when the reappearance of nephritic colic is to be feared, or in less simple cases where continual pain or turbid urine reveals a certain degree of inflammation or of catarrh in the region of the kidneys, the waters of Contrexeville-imported if necessary, but especially to be taken on the spot-are clearly indicated.

Bicarbonated and strong mineral waters, especially those of Vichy, are, on the contrary, to be avoided in such cases. We must insist upon this point, which is not sufficiently known to the majority of medical practitioners."1

In cases of phosphatic gravel (white gravel) nothing has given results to be compared to those obtained at Contrexeville.

The urine of patients suffering from this affection is either strongly alkaline or less acid than normal urine, and the patients see for themselves this phenomenon, at least surprising, that under the influence of the use of the water, slightly alkaline, of the spring of the Pavillon, their urine becomes more or less acid.

This is simply caused by the fact that the inflammation of their urinary channels disappears under the treatment, and the urine is restored little by little to its normal condition.

When gravel exists it is often passed out in small pieces, for this is far from having the consistency of uric acid gravel.

Gout, and more particularly atonic gout, is one of the affections which is most benefited by these waters. If anyone doubted the consanguinity of gravel and of gout, a season at Contrexeville would very soon undeceive him. It is, above all, a place for gouty patients suffering from gravel, and of patients with gravel suffering from gout.

Under the influence of the treatment the attacks of gout first become less acute and frequent, and then completely disappear, coming back again when the patient forgets the laws of hygiene.

Some of our patients, whose detailed history would be too long to give here, have not had attacks for six, eight, and even twelve years, when beforehand they had one or more attacks every year, either articular or visceral, for these manifestations of the disease are particularly benefited by Contrexeville.

"The waters of Contrexeville are often very useful in chronic gout. We have used them several times in cases of gout of long standing and we have found the results beneficial."

very

Dr. Potton, himself a sufferer from gout, and fighting,

Durand-Fardel: Traité pratique des maladies chroniques. Paris, Asselin, 1868, vol. i., p. 145.

as he says, "pro domo sua," has published1 a series of papers comparing the use of some of the mineral waters in gout; and speaking of visceral gout, he says that in these cases he chooses the calcareous magnesian waters of Contrexeville, as being preferable to all other remedies. "I do not know," adds the author, a surer means for regulating the functions in this kind of gout."

Vesical Catarrh, though sometimes met with in young men, is essentially a disease of old men, in whom the voluminous prostate and the uncontractable bladder occasion the stagnation of the urine, and its decomposition before its emission.

There is, perhaps, no disease against which so many medicines have been directed as against vesical catarrh.

At Contrexeville, after patients have drunk the water for a few days, the urine, which had been cloudy, thick, ropy, became clear, its mucous deposit diminishes, it emits a less disagreeable odor, the inclination to make water, which had formerly wakened the patient seven or eight times during the night, disturbs his sleep but once or twice; the feeling of heaviness in the abdomen passes off; micturition becomes easier, and the patients are delighted to see with what force they expel their urine. This improvement goes on increasing day by day, and ends in a definite cure after a season

Hepatic Colic.-The waters of Contrexeville have given equally remarkable results in cases of hepatic colic, particularly in debilitated patients. The laxative effect produced by the ingestion of the waters renders the indication precise in the case of hepatic patients whose intestinal functions are hindered. The Contrexeville waters possessing tonic qualities, are of great utility in the case of patients who have been debilitated by numerous crises.

Diabetes. Our personal experience confirms in all points the results which were described by Dr. Bronguiart, in 1876, in a lecture on the treatment of gouty diabetes, at Contrexeville. A number of gouty patients. are attacked with diabetes and many of them are aware of it only when the disease has become serious enough to render the cure problematical.

Among the cases we have observed we will mention two patients whose urine contained respectively one hundred and one hundred and twenty grammes of glucose to the litre. We saw this rapidly disappear under the influence of the treatment and without any special alimentary régime. In one of the cases the sugar reappeared the following year, the other we never saw again. But many other examples of gouty diabetes, with moderate quantities of sugar, have been followed by us, and the treatment always very happily modified the constitution.

When patients who had escaped our observation in the intervals of treatment came back to Contrexeville, the glucose, if it still persisted, was always to be found in much smaller quantities than the preceding year.

Among other affections which are benefited by the waters of Contrexeville we must mention dyspepsia, diseases of the prostate, chronic urethritis, spermatorrhoea, and uterine catarrh.

Clinical Department.

A CASE OF CROUP TREATED BY ANTI

TOXIN.

BY FORBES R. MCCREERY, M.D.,

NEW YORK.

THE question of the value of antitoxin is one of such great importance that I feel it desirable that even such individual cases as the following should be reported. It, of course, as will be seen, proves nothing for or against the remedy. Nevertheless, it is of interest, the more so as nearly all the reports heretofore published have been of hospital cases.

The patient, a child aged twenty-two months, was taken ill on the morning of December 2d. The symptoms first noticed were hoarseness, cough, and slight difficulty in breathing. These symptoms became gradually more marked. They were worse at night, but persisted throughout the day of the 3d. I first saw the child December 4th, about 10.30 A. M. There was no membrane visible in the throat, but the signs of laryngeal stenosis were well marked, though not extreme. The character of the voice and cough, the marked stenosis, and the history of the case, all pointed to the diagnosis of a membranous and presumably diphtheritic croup. That evening the stenosis was more marked, and I feared that intubation would be necessary before morning. I concluded, however, to try first the effect of antitoxin, and accordingly procured some from the Pasteur Institute and injected 13 c.c. The rectal temperature at the time was 101° F. The following morning I found the child free from laryngeal stenosis, but with a temperature of 102° F. I learned that the dyspnoea had begun to diminish within two hours after the injection. I injected about 6 c.c. more of the serum. That evening the child was still free from symptoms of stenosis and the temperature had risen to 105° F. I was informed that the child had been apparently delirious during the afternoon. The bronchi were full of coarse râles, and I thought I detected a patch of pneumonia. The child was given a tepid bath and an aconite mixture ordered. The next morning the temperature had fallen to 102° F. No pneumonia could be made out, and there was no stenosis. That day I received a report from the Board of Health stating that no diph

theria bacilli had been found in culture made from the pharynx; two subsequent examinations failed to reveal any. The child convalesced rapidly, without further symptoms than those of a moderate bronchitis. I may add that she had suffered from a severe bronchitis last spring.

Apart from the injection, the child was treated from the morning of the 4th by calomel fumigations and strychnia and iron internally.

I think this case is an example of a class often met with. I mean a class of cases in which all the symptoms indicate a membranous, and, therefore, probably a diphtheritic, laryngitis, but in which no membrane is visible, and in which no diphtheria bacilli are found in cultures. These cases, in my experience, are always serious, often require intubation, and are often fatal. It is safer always to assume that they are diphtheritic and to treat them accordingly.

In conclusion, I would repeat that the case proves nothing for or against the remedy. Nevertheless, the rapid disappearance of the stenosis seemed to have been due, in part at least, to the injection of antitoxin. In like manner, the sudden rise of temperature, and the delirium, may have been caused thereby.

POISONING BY POTASSIUM CHLORATE. BY THEODORE POTTER, M.D.,

INDIANAPOLIS, Ind.

Ar the meeting of the Marion County Medical Society, October 2, 1894, four cases of potassium-chlorate poisoning were reported by Drs. J. T. McShane, S. P. Sherer, Florence Hays, and myself. Two of these were fatal. The reports in brief may be found in the minutes of the meeting as published in the Indiana Medical Journal for November. The case which came under the writer's observation was as follows:

On June 21, 1894, I was called to see Mr. T, aged forty-seven, who was said to be suffering from painful bowel disturbances. He had been taken ill twelve hours before. He had vomited once or twice, and at the time of my visit complained chiefly of pain over the epigastric region and over the lower abdomen, with diarrhoea, which was assuming a dysenteric character. There was some rectal tenesmus, with the passage of small quantities of mucus and blood with the stools. Temperature 102° F., pulse 108 and weak. The bowels were ordered washed out, and bismuth and small doses of chlorodyne given.

On June 22d the morning temperature was 104.4° F.; evening temperature, 104° F., having been modified by small doses of acetanilid. On the 23d the temperature was 103° F. The fact that the patient did not pass much urine, and that there was some dysuria, was supposed to be sufficiently explained by the cholera-morbus-like attack of bowel trouble.

On the 23d, in spite of amelioration of the bowel disturbance, the other symptoms were no better, but in some respects worse. The patient complained at times of being cold; his feet were cold; fingers, nose, and cheeks cyanotic; he repeatedly broke into profuse sweat. The urine was scanty and there was considerable dysuria; rectal tenesmus moderate, with passage of some mucus and blood. The abdomen was very tender below the umbilicus and in the epigastric region. Weakness and prostration were out of proportion to the bowel disorder.

My attention was now called to the fact that the urine and the fæces were both black. The latter, it was thought, might be due to the bismuth taken, though the color was of an inky character, which, together with the black urine, aroused my suspicion. Inquiry was at once made in regard to the use of carbolic acid or potassium chlorate.

The patient stated that on the 18th, having a slight sore throat, he had bought two cents' worth of the latter drug, getting about two teaspoonfuls. This quantity he had eaten on the 18th and 19th. The poisonous effects showed themselves during the night of the 20th. The diagnosis of potassium-chlorate poisoning was now made.

The bowels were flushed repeatedly with hot water; large hot poultices placed over abdomen and back. He was ordered hot sitz-bath, castor-oil was given, and he was directed to drink large quantities of weak flax-seed tea. Small doses of Dover's powder were also given.

On the 25th the morning temperature was 101.5° F. There was dribbling of urine, and examination showed retention; urine still very dark, though not black. In the evening the catheter drew about twenty ounces of better-looking urine. The stool resulting from the castor-oil was more natural in appearance, but subsequently and for a week the fæces were almost black, though the bismuth had been discontinued.

The treatment was continued as above, except the poultice to the back. The diet was milk, soup, broth, and fresh beef-juice. At times watermelon-seed tea was substituted for that made from flax-seed. The catheter was used twice daily till July 2d, the character of the urine in the meantime improving.

The patient had for several years shown some signs