of the lower border, which had not yielded to treatment, and who also had symptoms indicating duodenal difficulty from previous duodenal lesion. Dr. Russell at once recommended gastro-enterostomy. At the operation old duodenal lesion. with adhesions was found of such a kind that would have made an attempt at medical treatment ridiculous. She also did well, and was much benefited by the gastro-enterostomy. This patient had been diagnosed a year before as a neurasthenic; but blunders of this kind are no more to be taken as the standard of the physician's work than the blunder of opening the abdomen unnecessarily is to be taken as the standard of the surgeon's capacity. The aim of the physician ought ever to be to reduce the margin of error in internal diagnosis to vanishing proportions.

ELECTRICAL TREATMENT OF INFANTILE PARALYSIS.

Zimmerman and Bordet, in Archives d'Electricite Medicale, make an exhaustive report upon the whole question of electricity in the treatment of infantile paralysis. The treatment, they state, is based upon precise physio-pathological indications-it is a rational therapeutic. Its principal purpose is to reduce to a minimum the infirmities caused by the medullary lesions, and to restore as far as possible the voluntary contractility of the muscles. Of all the physical agents, electricity is the only one which is capable of provoking a muscular contraction analogous to the voluntary contraction. Massage does not produce the physiological contraction of the muscles, and the misleading appearance of suppleness to which this method gives rise when it is used by itself renders it inadvisable. As an adjuvant to electrotherapy, the authors are of opinion that the role of massage is an insignificant one. The choice of a current depends upon the results of electro-diagnostic exploration. If the muscles have conserved faradic excitability, recourse may be had to the currents of the induction coil. Galvanic interrupted currents are employed when the degenrate muscles respond to that form of excitation. Great care must be taken to avoid fatigue, and the authors proscribe the automatic electrization of groups of muscles. Electrical intervention should be made very cautiously at the beginning of the treatment. There should be no attempt to make a complete electro-diagnosis at the first seance. When the treatment is fully established the seances may last for an hour, providing always that there is no fatigue. The repetition of the seances should be very frequenttaking place every day during the active period of treatment, and, if possible, twice a day. The

duration of the whole treatment, unfortunately, must be counted by years. It is rarely that one year suffices, more frequently it requires three. The treatment may be suspended with advantage during the summer months, and the patient sent to the seaside or the mountains. This change of air, without acting directly upon the paralysis, is of value to those children whose general state has suffered from their inactivity. During the second year of treatment the authors counsel the use of light orthopaedic appliances, and during the third year these, together with kinesiotherapy, may be increasingly employed, while the degenerate muscles are still electrized with persistence. The cessation of treatment is indicated when, for many months, the amelioration has shown no progress, either from the point of view of the voluntary movableness or from that of the electrical reactions. Summarizing the whole subject, the authors state that if the treatment is started sufficiently early and continued with method and persistence, it produces, as a rule, in the course of time a reduction of the impotence and a return, more or less remarkable, to functional power.

慌慌慌

TREATMENT OF FEMALE GONORRHEA. John B. Talmage, in Merck's Archives, gives the following treatment for the urethra and vagina in female gonorrhea:

The Urethra.-The acute stage is treated constitutionally the same as the bladder. Local treatment is not instituted until the acute symptoms have subsided. Short as the urethra is, there is not another portion of the female genital tract, except the cervix, which causes so much trouble, and in which the gonococcus lodges with so firm a hold. With the onset of the subacute or chronic stage the treatment must be very thoroughly and systematically carried out. Thousands of remedies have been tried, and none of them can stand the test of all kinds of cases. The two best drugs are argyrol in solution from 20 to 50 per cent, and silver nitrate in solutions from 1:1000 to 30 per cent. Argyrol in 20 to 50 per cent solution should be thoroughly massaged into the urthera by the aid of the urethascope and an applicator wound with a small amount of cotton, so that too much of the drug may not be used. This remedy must be used frequently and for long periods before smears from the urethra will be negative under microscopical examination. Silver nitrate irrigation in solution of 1:1000, gradually increasing the strength to 1:500, is perhaps preferable. Skene's ducts and the small follicles of the urethra must be thoroughly massaged clean of their accumulated secretions by the finger in the vagina. If the openings of these

ducts are seen to be chronically inflamed, they must be slit up with a fine knife and the lining membrane thoroughly eradicated, either by electric cautery or carbolic acid pure, followed by 95 per cent alcohol to prevent too much destruction of surrounding tissue. This can easily be accomplished under cocaine anesthesia. Any ulceration seen by the aid of the urethrascope should be painted with 20 to 30 per cent solution of silver nitrate applied carefully. The surfaces so cauterized should be wiped dry, so as not to leave any extra fluid of this strength in the canal. The Vagina. The acute vaginitis is best treated by warm douches of a solution of potassium permanganate 1:1000 or 2000. The vagina is to be ballooned out and the folds of mucous membrane eradicated by compression of the lips of the vulva around the douche tip; when fully dilated the pressure is relaxed, and the imprisoned fluid and secretions escape, and then the process is repeated again. Once a day a 10 per cent argyrol solution should be thoroughly swabbed in the vagina, and a tampon soaked with the same solution is inserted and left for three or four minutes; after this is removed and the vagina wiped dry, a large tampon dusted with dolomol and tannic acid powder is inserted and left until the next douche. If the vagina is too sensitive, the tampon treatment may have to be delayed for a week or ten days, and nothing but the douches and hot sitz baths given, with hypodermatic injections of morphine and atropine if pain is of great severity. When the disease has become subacute or chronic, the treatment must change to a more astringent and caustic variety. Here zinc sulphate, grn. xxx to the quart of warm water, and bichloride of mercury, 1:2000, hot, are to be alternated with each other, four douches altogether in twenty-four hours. When ulcerations are present they should be painted with 5 to 10 per cent of silver nitrate. Tampons soaked with boroglyceride should be inserted and left for twelve to twenty-four hours to relieve congestion every two days. During these periods the douches should be stopped.

TREATMENT OF FRACTURES. Emory Lanphear, in the Southern Practitioner, teaches that the time for operation in any fracture is the earliest moment that consent of patient can be obtained and the services of a competent operator secured. If delayed until the rarefying process is well advanced, the chances of securing good results are vastly diminished.

Whenever possible radiographs should be secured prior to as well as immediately after operation. These establish the necessity for oper

ating and prove the skillful repair of the injury. The advantages of open treatment, even in cases heretofore regarded as not demanding operative interference are (1) immediate relief from pain due to (a) movement of fracturesurfaces and (b) tension from extravasated blood; (2) accurate approximation of end; (3) perfect retention of ends of bone, thereby preventing (a) deformity and (b) shortening of the limb; (5) removal of interposing structures—of especial import in fracture of patella; (6) removal of clots; (7) repairing injuries to neighboring structures-torn tendons, lacerated ligaments, bleeding vessels, etc.; (8) prevention of excessive callus-a most important point, when the fracture involves or is near to an important point; (9) fragments of bone which might greatly prolong perfect bony union,or even form sequestra) may be removed; (10) earlier and more perfect union may be secured-if there be no infection by operator or assistant. With favorable suroundings and an experienced operator no physician need have any hesitancy in advising the conversion of a closed fracture into an open

one.

It is perhaps unnecessary to state, at this late date, that both operator and assistant should wear rubber gloves and that gauze and towels as well as instruments should be boiled for twenty minutes in 2 per cent carbonate (not bi-carbonate) of soda at time of operation, if done outside of a hospital with modern sterilizing outfit; and that the most scrupulous care must be exercised not to infect the simple fractures nor to further infect the compound ones by introduction of more cocci of suppuration through careless handling or injudicious attempts at securing perfeet cleansing of the injured tissues.

For cleansing the wound in compound fractures perhaps tincture of iodine in full strength, rubbed in with a piece of gauze, is the best germicidal agent we possess. When the injured surfaces are covered with dirt, mixed in grease, gasoline may be used for first cleaning, followed by the iodine. No scrubbing of abraded surfaces with brush or gauze is permissable, as it would disseminate the germs and cause serious trouble in cases which otherwise might be cured with

ease.

In the use of plaster of paris for splinting, it is best to make troughs rather than to apply (as is usually done) as a roller-bandage. Or if applied as a bandage the front part should be cut away so as to permit of frequent dressings of the injured soft parts without contamination of all of the gauze and other envelopes of the limb.

story, supplemented by the history given by the

nurse.

REST AND MOVEMENT IN TUBERCULOSIS.

R. W. Phillip, in the British Medical Journal, asks how we are to apply the principle of alternate rest and movement to the varying manifestations of disease which occur?

So long as the tuberculous process is in active operation toxins are readily elaborated and passed freely to the muscles with sultant progressive dystrophy. This dystrophy affects not only the muscles of the trunk and extremities where it is evident, but affects likewise the heart muscles, the muscles of the vessels, and the muscles of other viscera. At this stage the indication for treatment is mainly rest. Rest has the double advantage of tending to stay the active local lesion and of limiting the output of energy by the dystrophic muscles.

On the other hand, when the tuberculous lesion is less active or in process of arrest, and the production and carriage of toxins is correspondingly less abundant and rapid, the dystrophic muscles tend to recover themselves physiologically.

Nothing repairs muscular tissue so certainly as natural movement. This is the motif and guide in the institution of regular activity.

The author recalls the fact that tuberculosis tends to occur more frequently in persons who lead a sedentary, or at least a relatively inactive, life. This is not an absolute rule, but its application is a wide one. He goes further and says that, in proportion as the individual whose work involves a sedentary existence indoors counteracts the fault of his life by regular activity in the open air after working hours, the tendency to tuberculosis is limited and may be overcome.

The author reminds us that the same principle may be traced in comparative pathology. Which are the animals most frequently affected by tuberculosis? Not the dog, not the horse, not the goat. It is the stalled cow which suffers most; and of the bovine species there is a marked difference as to frequency between comfortably. housed milch cattle and Highland cattle living a relatively active out-of-door life during the greater part of the year.

It is likewise freely admitted that nothing so certainly checks the earliest threatenings of tuberculous disease in the child, whether in glands, lungs, or elsewhere, as turning the patient out into the wild and letting him lead the natural, active life of the Highland pony.

It is a different matter when the tuberculous process is further advanced and lung destruction is in progress. Here we are face to face with

morbid conditions, both local and general, which are best met by rest.

Take, for example, the occurrence say, the repeated occurrence of bleeding from a cavity within the lung. It goes without saying that here rest, both mental and physicial, is to be enjoined. Again, where the lung is breaking down rapidly and there is continued absorption of poisonous products, with corresponding systemic intoxication, evidenced by disturbance of temperature, increased pulse-rate, and rapid muscular wasting, rest must be the order of the day. The excessive waste must be met by economy in wear and tear. The circulation, which is the chief channel of dissemination of the poison, must be kept as quiet as possible.

As acuter manifestations disappear under the influence of rest, and the risk of local and constitutional disturbance is reduced, the need for complete rest is lessened or removed. This is in keeping with the facts of pathology in relation to other acute morbid processes.

As recovery proceeds further, the aim comes to be the restoration of physiological functionboth locally, so far as the respiratory function of the lung is concerned, and generally, so far as the circulation and musculature are concerned. The process of repair is most readily traceable in the muscles of the trunk and extremities. By the institution of natural movements, the physiological cure or "recreation" is assisted, and there follows a gradual return towards the normal condition of health of every organ. The author reminds us that, for us all, health is largely governed by the harmonious alternation of activity and rest.

While natural repair is thus hastened by carefully adjusted movement, there is reason to suppose that at the same time a degree of relative immunization to tuberculosis is secured. It may be that under the influence of activity a process of autoinoculation is instituted. That is to say, by reason of the accelerated circulation a certain amount of toxin is carried through the system. The presence of the toxin stimulates the system to react and to produce certain opposing elements or antibodies.

If we can adjust the activity so nicely as to lead to the discharge of just so much toxin as will cause a serviceable and not an excessive reaction, we may hope to achieve by natural methods what we seek to effect in the treatment of tuberculosis by vaccine therapy-that is, by the use of tuberculin.

It will be readily understood that during an acute tuberculous process, with disintegration of lung tissue, the manufacture of toxins and their

subsequent discharge into the circulation may be in excess of the possible production of antibodies by the system. The tissues are thus left to soak in a highly toxic element, without the antagonistic influence which in less acute processes Nature herself is able to provide unaided or may be induced artificially to afford.

NON-PURULENT EAR DISCHARGES.

W. M. Molliston, in the British Medical Journal, points out that such discharge may come from the pinna, the meatus, the middle ear, or the cranium.

(a) The Pinna. A common condition met with here is an eczema, seen often in children and often passing to an impetigo; it is either a primary infection or secondary to a suppurative discharge from the middle ear. This condition is best treated by the daily application of a 5 per cent solution of silver nitrate combined with some ointment for home use either boracic or yellow oxide of mercury; under this it is remarkable how quickly improvement follows.

(b) The Meatus. Wax is a common cause of discharge, especially when it has been present some time. Removal by syringing is the obvious treatment. Should difficulty be experienced in this removal, a few drops of hydrogen peroxide, 5 or 10 volumes per cent, will facilitate matters. Meatitis. There are many causes of meatitis, but the commonest are an eczema and suppuration of the middle ear. An eczema may be localized to the ear, or may be part of a general eczema. It gives rise to a scaling of the meatal wall and a thin serous discharge. In many cases this discharge does not come out from the ear, but forms a collection of debris, consisting mainly of desquamated epithelium, in the deep parts of the meatus, very irritating, and causing deafness. This collection of debris often occurs in the groove formed by the floor of the meatus and the anterior inferior part of the membrane, which meet at an acute angle. Painting the meatus with the 5 per cent solution of silver nitrate two or three times a week gives good results. In the cases where the debris collects, this must be carefully and thoroughly removed with the aid of a fine probe armed with small pieces of cottonwool. It may be a tedious performance, but the results are most gratifying, and well repay the time spent. For the patient's own use, a few drops of the following, used every night, will be found most useful in allaying irritation and preventing the scaling:

R Ung. hydr. nit. dil...
Ol. amygdalae

3j .ad 3j

Should this not be satisfactory, perhaps ung. picis

carbonis will sometimes prove useful. Meatitis in adults and children often causes great narrowing of the meatus, making a view of the membrane very hard or, indeed, impossible to obtain. Very frequently this marked narrowing without any obvious otorrhoea is due to a perforation in Shrapnell's membrane. In these cases as well as painting with silver nitrate, packing the meatus tightly with strips of gauze will soon cause dilatation. This should be done every day until finally a good view is obtained of the Shrapnell membrane fistula, which can then be treated.

Blood from the meatus is unusual and perhaps should not be included in my list, but the condition is so interesting that the author includes it. It is the result of self-inflicted injuries, and is seen, as a rule, in girls of a neurotic disposition. The following case is an example:

was

A girl of 17 had suffered from almost daily hemorrhages from the ears for nine months. For six of these months she also had frequent epistaxis. Her medical man had her under constant observation, suspecting self-inflicted injuries, but never was able to detect her. She was a healthylooking girl-described as a tomboy when at school-but her look somewhat furtive. Examination of the ears revealed nothing abnormal and she heard perfectly; in the nose were seen scabs on either side of the septum. She was put under observation, and during the first two days her ears bled twice, on both occasions while the nurse was absent from the room. One ear was then covered with wool and gauze and sealed with collodion; she bled from the opposite ear; this was then covered in a similar way and no bleeding occurred at all. Her mother was told; and some weeks after sent the report that the attacks of bleeding had practically stopped and the girl was much better and brighter.

(c) Middle Ear. Discharge of blood occurs as a result of rupture of the tympanic membrane; the tear is usually found in the posterior part of the membrane, and follows a blow on the ear or a severe fall on the head, or, as the author saw recently, a dive from a height, coming down with the side of the head on the water. The treatment must be directed towards keeping the meatus aseptic, not by syringing, but by the insertion of a strip of antiseptic gauze, or perhaps by a plug of aseptic wool.

(d) Cranium. In fracture of the base of the skull across the middle fossa discharge of blood and cerebro-spinal fluid occurs through the almost invariably accompanying rupture of the tympanic membrane. Treatment here must, as far as the ears are concerned, be as for the cases of ruptured membrane-aseptic wool plugs in the ears.