infecting agency is benefited by the treatment, one may be easily led to try it for other infectious diseases. As a matter of fact he has tried it for many others, including typhoid with severe bronchitis, whooping cough with bronchitis and convulsions, with excellent results. It seems to him the ideal treatment for all forms of septic fever. The only regulation is to make the patients com. fortable, keeping their feet warm especially. The ears, nose and hands may get cold without harm. The Presbyterian Hospital is so convinced of the permanent usefulness of open-air treatment for all infectious fevers, that it has built a roof garden for the children's ward, and is about to build on the

main roof of the medical side of the hospital a collossal roof garden. One-half of this has a "horse shed" structure, the shed open to the south, and a liberal space in front, enclosed, like a paddock, for a roof garden. In bad weather the beds of the fever patients are to be wheeled back into the depths of the shed. In good weather they will be advanced to the opening, or even out into the garden. They will remain there night and day, so long as their fever is high. It is an open-air ward.

Vascular Tension in Chronic Illness.-Hare (Amer. Jour. of Med. Scs, Aug., 1906) calls attention to the importance of study ing the vascular system in respect to the treatment, diagnosis and prognosis in many diseases. He emphasizes the fact that many medical men still labor under the assumption that an exhausted heart should receive stimulation when in reality it should be given as much rest as possible. The heart is often competent to do its work when the contrary is suspected, if vascular relaxation is overcome, and in such instances active cardiac stimulation is more harmful than advantageous. According to the author's experience the three drugs useful for this purpose are atropin, adrenalin and digitalis There may be distinguished three classes of high arterial tension in relation to cardiac failure: (1) Those in which the spasm result from prolonged nervous stress associated with improper habits of living. (2) Those in which in addition to spasm there is fibroid change in the vessels. (3) Those in which high tension is followed more or less suddenly, by low tension, the arteries resembling veins in their calibre and compressibility. Hare sugHare suggests the following rules to clinicians: 1. Cardiovascular stimulants should not be given when careful reflection will show that cardiac relaxants are appropriate. 2. More attention should be paid to protecting the heart from unnecessary labor. 3. If the ves

sels are properly treated the heart will in many cases take care of itself. 4. The heart should not be stimulated when the aim is to diminish its burden and diminish toxemia.

On the Influence of Rest, Exercise and Sleep on Gastric Digestion.-Friedenwald (Amer. Med., Aug., 1906) reviews the literary aspects on the subject and deducts the following conclusions based on a study of ten investigations of both normal and pathologic subjects: In persons with normal digestive powers it makes but little difference whether the individuals rest, exercise, or sleep after work; though after violent exercise or sleep the gastric digestion is very slightly impaired. subacidity it is best to order rest after meals; In patients suffering with superacidity and after violent exercise or during sleep, the digestion is impaired in these cases. In patients suffering with motcr disturbances of the stomach, it is best to prescribe moderate exercise after meals, for rest, violent exercise, or sleep disturbs the digestion under these conditions.

The

Postcritical Fever and Other Sequela of Croupous Pneumoni 1.-Talley (Jour. A. M. A., Sept. 8, 1906) bases his article on a study of 325 cases, reporting in detail 18 cases which gave rise to febrile symptoms after the crisis, including among them empyema, abscess, endocarditis and pericarditis, relapsing pneumonia, pleurisy, bronchitis, otitis media and meningitis, parotitis, hemorrhagic nephritis, thrombosis and neuritis, and colitis. causes, then, he says, of postcritical fever in croupous pneumonia are evidently manifold, and the exact cause can be determined. in a given case only by careful and repeated examinations of the patient. Even when such examinations are apparently negative one should be slow in attributing the fever sim. ply to delayed resolution or autolysis alone. The number of small abscesses found in the stage of grey hepatization, post mortem, would incline one to believe that it is not alone the slow resolution, but perhaps more often a varying degree of this purulent tendency, especially in the stage of grey hepatization, that explains the fever. Though the abscesses are usually multiple, one case showed distinctly one small abscess which in itself might have caused the persistence of fever, and it is conceivable that such an abscess may discharge undetected, or, surrounded by an encysting wall, be gradually absorbed and the patient recover without the exact cause of the fever ever being known. Even an encysted empyema, if small, may be hard to demonstrate. The X-ray, he states, is of rather doubtful value in detecting such conditions. It is the common experience of a

thickened pleura in this class of cases that renders the X-ray of less value. It is doubtful if the number of endocardial and pericardial involvements in his series really represents the vast importance that must be attached to this cause as the factor in many fatal cases. One must be alert for this complication, especially in patients who have an old endocarditis or atheroma. The author's cases show that the right side of the heart is by no means free from serious involvement. The development of a systolic murmur may be explained by the anemia well known after penumonia, or by the relative insufficiency due to the weakened heart muscle, but the development also of a diastolic murmur usually means that there is genuine endocarditis, as is proven by autopsies.

The Care of Far Advanced Cases of Pulmonary Tuberculosis.-Bonney (Buston Med. and Surg. Jour., Aug. 30, 1906) elaborates on the treatment of far advanced cases of consumption, emphasizing that the principles ap plied in the incipient cases, as suitable régime, rest, out-door air, and superalimentation should be all the more adhered to in the advanced cases. The measures which he employs in the advanced stages are the most complete interpretation of the rest treatment and the use of the antistreptococcic serum. Regarding the use of the latter he says: About one case out of every four or five may reasonably be expected to exhibit a pronounced diminution of temperature by the end of a week or ten days. The remaining cases do not show any bad results from its employment, other than those due to the occasional intolerance of the system for the serum of a horse. This so-called reaction, which is independent of the specific nature of the remedy, but common to all other serum preparations, bears no relation to the ultimate results obtained. Some cases show marked improvement in spite of temporary discomfort in the way of chills, fever, uticaria and painful swelling with stiffness of the joints, while others exhibit no improvement, although there is entire absence of constitutional disturbance. Reaction may take place within twelve hours after the use of the serum, or it may be delayed for six weeks. Occasionally the improvement is delayed indefinitely until the occurrence of the reaction, following which there may be complete and enduring subsidence cf the fever. As a result of the serum the temperature either may subside to normal or may be reduced several degrees, remaining, however, somewhat elevated. Bonney does not favor its continuous subcutaneous employment, and

has given, as a rule, not over four or five doses at intervals of one or two days and waited results. During the past nine months he has practiced the tentative administration of the remedy by the rectum for ten or twelve doses before resorting to its hypodermic use, in order to avoid the discomfort which sometimes follows its injection into the tissues. He has seen unquestionably good results attend its use even when streptococci were not found in the sputum, and believes that even under such conditions the clinical evidences of a persisting sepsis may sometimes afford, from a humanitarian standpoint, a warrantable basis for its use.

THERAPEUTICS.

W. T. HIRSCHI, M.D.

The Absorption of Fat in Pancreatic Diseases (Hirechstein, Arch for Exp. Pathol. ogy and Pharmacology.)-Fats are changed into fatty acid, glycerin, etc., in the intestinal tract, even in the absence of pancreatic secretion and bile. tion and bile. Only the glycerin is absorbed however, and the fatty acids appear in the stools, saponified or combined with alkalies. Other substances must take the place of bile and pancreatic fluid, and it seems as though gastric steapsin and bacteria take their place. Steapsin loses its function in an alkaline medium, and consequently is most active in the stomach and in the lower part of the large intestine, but its action is very mild. Bacteria convert about 9 to 13 per cent of the fat into its component parts. The author removed the pancreas, liver, small intestines and spleen from dogs, and expressed the secretions from them, to determine their power to emulsify fats. He came to the following conclusions: Pancreatic and hepatic expressed fluid is most active from hungry animals. The blood corpuscles are more active than blood serum. The most active is a combination of pancreatic and splenic fluid.

The Treatment of Bronchial Asthma.-Zenlzer (Ther. der Gegenwart, No. 9, 1906) reviews the different causes of bronchial asthma, and lays particular stress on the muscular spasms in the bronchi, and the acute enlargement of the lung tissue. Animal experiments prove conclusively that an irritant applied to the vagus produces an acute pulmonic enlargement and asthmatic attacks. If, how

ever, the animals receive atropine injection previous to the vagus irritation no such attacks are apt to occur, and this suggests the use of atropine in the treatment of asthma.

The vagus irritation plays a most important role in the cause and symptoms of bronchial asthma. The catarrhal affections play a secondary role, which can easily be demonstrated in many cases by the almost complete absence of catarrhal symptoms. One mg. atropin, hypodermic, relieves many cases of asthma in a very short time, and the lunge contract to their normal size. Since hysteric individuals bear atropin very badly we must use it caustiously in these cases, or combine it with morphine. Many nostrums which are advertised for the cure or relief of asthma contain atropin, but it is far preferable to use the drug hypodermic, and regulate the dose more accurately.

Nervous Liver Colic.-(Ewald, Berlin, Ther der Gegenwart.) The severity of the attack, the seat of pain and the recurrence of the attacks of nervous liver colic cannot be differentiated from those due to gall-stones or organic liver diseases. In females these attacks are apt to occur during menstruation, and other nervous, hysterical or neurasthenic symptoms accompany them. The abuse of alcohol, tobacco aud spicy foods often bring on an attack. Jaundice, hepatic enlargement or enlargement of the gall bladder very rarely exist. The treatment of the nervous condition frequently relieves the patient of the colic. Frequently the diagnosis is not made until the surgeon makes an exploratory laparotomy, or the case terminates fatally, and the autopsy reveals the exact condition. The

author reports several cases that he diagnosed gallstones, and the following operation failed to show any abnormality about liver, gallbladder or ducts.

Dietetic Treatment of Basedow's Disease.Alt (Münch. Med. Wochenschrift, No. 24, 1906) obtained splendid results in the treatment of myxedema and Basedow's disease by paying close attention to the diet. The food should contain very little salt, especially if edema is present, or if the heart beat is greatly accelerated. Carbohydrates are not well tolerated and are not well absorbed, and, there fore, it is better to reduce them in the diet. Albuminous substances and fat in the form of milk, cream, butter, ice, meat, eggs and fish are very beneficial. Phosphorus should be administered to balance that lost in the rapid metabolism and eliminated by the kidneys. He reports twelve cases, of whch all showed a decided improvement in the subjective and objective symptoms.

Tuberculin in the Treatment of Tuberculosis-with the Report of 167 Cases.-Pogue M ed. Rec., Aug. 4, 1906) from a study of h is series of cases draws the followng con

clusions: An early diagnosis is the most im portant step to the successful treatment of tuberculosis. Tuberculosis may be arrested by proper treatment, with a fair certainty of a permanent cure. Tuberculin is a valuable adjuvant in the treatment of tuberculosis, as evidenced by the recovery of twenty-eight out of thirty cases that were treated with practically nothing but tuberculin, while they continued to follow their ordinary occupations during the treatment. Cases of tuberculosis treated with the addition of tuberculin showed far less tendency to recur than did similar cases treated without tuberculin. Tuberculin in small doses (0.1 to .5 mg.) seems to have a more curative action than when given in large and increasing doses. No ill effects follow the administration of small ones of tuberculin.

Purely incipient cases improve very rapidly under the use of small doses of tuberculin, both as to the arrest of the disease and the clearing up of the diseased area. Tuberculin should never be given to a patient who has fever or who is suffering from mixed infection. Third stage cases, especially advanced cases, receive little or no benefit from the use of tuberculin.

Ethyl Chlorid as a General Anesthetic.Hawley (Jour. A. M. A., Aug. 18, 1906) discusses the merits of ethyl chlorid as a general anesthetic. He reviews briefly the literature on the subject and finds that various writers give diametrically different opinions. Hawley states that after several years of more or less constant use of ethyl chlorid both in clinical and in private practice, he has still to see the first case to cause him the slightest fear of uneasiness. He declares that when used with care and understanding he prefers ethyl chlorid to any other anesthetic, in short operations, except, perhaps, nitrous oxid gas. He states that the following precautions should be observed: (1) The patient should be prepared as for chloroform or ether; (2) whatever mask is used it huold fit the face snugly; (3) a graduated tube with a large aperture should be used; (4) the anesthetic should be well supplied with air and as little given as possible; (5) care should be taken not to present it at first in too large a quantity, frequently a dram is sufficient for short operations; (6) the patient should rest a while after its administration, as faintness sometimes supervenes; (7) a mask should be used which does not receive the drug close to the patient's face; otherwise one is liable either to freeze the face of the patient, or to cause asphyxia by the moisture from the expired air freezing on the ganze in the mask, and thus preventing the free passage of air to the patient.

GENITO-URINARY.

T. A. HOPKINS, M. D.

Three Ureters Demonstrated During Life; Ureter Catheterization Giving Three Different Urines. One Infected with Gonococci. Lewis (Med. Rec., Oct., 1906) reports a remarkable case of three ureters in one patient: Three catheters, armed with wire, were successively introduced into the three ureter openings and pushed up toward the renal regions, after which two X-ray photographs were taken, with very satisfactory results. This skiagraph made it evident that the ureter on the right side of the body had no connection with the two on the left side. Those of the left side, after leaving their respective openings at the angle of the trigone, run parallel with one another in following the direction of the pelvic hexagon, and ascended in the manner usually followed by the left ureter. Whether because he did not push it as far as possible or not, one of the catheters ended at a point something like three inches lower than the other. The two ureters instead of maintaining their relative positions, crossed one another in making their ascent. The one starting from the median vesical opening led to the outer side when it reached the flank, while the ureter that started from the outer opening crossed and obtained the median position in the flank. This one was infected with gonococci, the other two having been perfectly healthy.

It

Urethral Diverticula and Cul-de-Sacs. Aaronstamm (N. Y. Med. Jour., Oct. 13, 1906) after emphasizing the importance of detecting defects of this class states that the treatment thereof is decidedly simple. consists in first discovering the precise location of the sac or canaliculus by means of the urethroscope, or if this be not available with a small sound or probe; or a very fine olivary bougie may be used. With the former in position, the lacunar fold is then slit open with a small knife or tenotome throughout its entire extent to the very bottom of the urethral mucosa. Or, after the site of the channel or sac has been located, a urethrotome may be introduced, and by a sweep of the delicate blade the pocket divided Local anesthesia usually suffices to accomplish this result. As soon as the fold of mucous membrane has been severed, this should be followed by the insertion of sounds in ascending sizes until the largest can be conveniently passed, and left in situ for at least ten minutes each time. This must be continued for a week or ten days to prevent the too premature closure or healing of the divided edges or subsequent fibrous contraction, which may ulti

mately lead to stricture formation. Rarely is the fold of mucous membrane so extensive as to require ablation or removal in toto. The two lateral bands become eventually atrophied and at a level with the urethral canal. ́ Another method that may be utilized consists in the dilatation of the urethra either by means of a urethral dilator or what is still simpler with a pair of ordinary dressing forceps gently introduced and expanded to its utmost limit, provided, however, that the cul-de-sac is not situated too far posteriorly, severing the band by means of a small scissor, and then proceeding in the manner already de

lineated.

Vesical Tuberculosis.-In a recent address on the subject of vesical tuberculosis before the New York Academy, Pedersen stated (N. Y. Med. Jour., Oct. 6, 1906) that this was a disease of early adult and middle life, more frequent in men than in women, and almost invariably secondary. It was a disputed question whether it was secondary to dis ease of the kidney or of the genital organs. It was also a mooted point whether infection generally took place through the blood or the lymph vessels. No weight was attached to infection by tuberculous urine or semen. Some authorities stated that the urine maintained its acidity, others that it became alkaline. Pus in the urine denoted a mixed infection. The presence of tubercle bacilli in the urine was the one pathognomonic sign, but failure to find them was not conclusive negative evidence. The diagnosis. was difficult in the early stages, but not so later. Pain, frequency of urination, and hematuria were the cardinal symptoms. Cystoscopy would show patchy hyperemia, erosions, or ulcerations. Search should be made for tuberculosis of other organs. A sign of some value was the fact that the bladder was intolerant of mild solutions of silver nitrate, but this was also true of some cases of vesical calculus. Strong solutions acted favorably. It was the consensus that in the early stages the treatment should be mainly hygienic and dietetic. Creosote and guaiacol were good. Instillations were preferred to irrigations as a general thing. When the frequency of urination and the tenesmus should be drained. could be controlled no longer, the bladder Kelly excised the ulcers. The prognosis of vesical tuberculosis was universally conceded to be bad.

Hypospadias. Stinson (Jour. A. M.A., Vol. xlv, No. 23) describes his method of operating for hypospadias anterior to the scrotum in the following steps: First, he performs an external perineal urethrotomy and inserts & large tube into the bladder so that all the