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Chronic appendicitis may be shown in two ways: First, by the ileal stasis which it produces; and second, by actual demonstration of the kinked and adherent appendix. By "ileal stasis' we mean retention of bismuth in the terminal loops of ileum for a longer period than is normal. Normally, six hours after our test meal, the bismuth should not only be out of the stomach, but also nearly completely out of the coils of ileum. Many perfectly healthy persons, however, will show a small amount of bismuth still present in the terminal ileum at the six hour examination. To be safely classed as real ileal stasis bismuth should be present at least twenty-four hours or longer. From the presence of marked ileal stasis alone we cannot make a diagnosis of chronic appendicitis; but we can sometimes infer it. It is, however, just this method of inference that has served to bring much of the Roentgen bismuth work into disrepute among careful physicians. As in other departments of Roentgen diagnosis, the aim should be to find some factor that offers positive, not inferential evidence.

This positive evidence is found in the actual demonstration of the appendix itself, that is of the bismuth mixture within the lumen of the appendix. The fact that the appendix can be demonstrated Roentgenologically is today known to only a small proportion of our surgeons, and even of the Roentgenologists. Only two months ago, Groedel, one of the foremost of German Roentgenologists, published a paper in which he claimed to have demonstrated the appendix in three cases, all of which were pathological; and he showed a print of one. From this extensive series he concluded that the normal appendix cannot be demonstrated by the Roentgen ray; and conversely that an appendix which can be demonstrated by this method is pathological. Of course this evidence is ridiculously insufficient.

Pathological appendices have been shown for many months by Jordan of London who does the Roentgen work for Lane at Guy's Hospital. In this country, Case of Battle Creek over six months ago published a large series of over sixty cases in which he had demonstrated the appendix, some normal, most of them pathological. Case also inclined to the view that an appendix that can be filled with bismuth, if not definitely pathological, is at least a potential danger. We will agree with him in those cases where bismuth remains in the appendix for forty-eight hours or more, when it has passed out of the surrounding intestinal tract. In the other cases, where the size, shape and position of the bismuth shadow correspond to a normal organ, we

do not believe that the potentiality for danger is any greater than is always associated with any unremoved appendix. Since our attention was called to the appendix by Case we have succeeded in demonstrating this organ either normally or pathologically in about seven out of every ten cases examined. In many cases the normal condition was verified at a later operation for other purposes.

A pathological appendix can of course only show itself, if its lumen is unobstructed, at least in part. It may show a bismuth mass which is sharply kinked in one or more places. There may be adhesions to itself, to the cecum, ileum, or even to the sigmoid. We have shown an appendix wrapped around and adherent to the terminal ileum so as to obstruct the latter. Retrocecal appendices can sometimes be shown distinctly. Often these are obscured by the dense mass of cecal bismuth; and will show up more clearly when some of the bismuth has passed out of the cecum.

In many of the cases bismuth will persist in the lumen of the appendix for many hours after it is out of the cecum and ascending colon; in one of our cases as late as five days after the ingestion of the bismuth meal. Of course in these cases the appendix is definitely pathological, but usually the abnormal condition is manifested by accompanying adhesions or kinks. Occasionally an appendix which is not shown on the plate may be definitely pathological, but usually the abnormal condition is manifested by accomappendix which is not shown on the plate may be definitely filled out with the bismuth mass by massage under fluoroscopic control.

GLAUCOMA IN GENERAL PRACTICE. Some excellent advice for the general practitioner anent the treatment of glaucoma is found in an article in the Lancet-Clinic for November 22. written by Dr. K. L. Stoll. He declares that early treatment of glaucoma is imperative because spontaneous recovery is not likely to occur. Blindness is the unavoidable fate of neglected cases. The prognosis is unfavorable even in certain types of glaucoma which come early under expert care, and usually an operation has to be resorted to.

Local treatment, however, is of the greatest importance as "first aid" at the hand of the oculist, and still more of the general practitioner, who has more frequently occasion to see the beginning or even the prodromal stages. The miotics, eserine and pilocarpine, used first in 1876 by Laquer, of Strassburg, are the principal standbys of local therapy. Cocaine and organic adrenalin preparations must be used with care, as they dilate the

pupil and produce a hypotony followed by a rise of tension. Synthetic L-suprarenin may be employed with safety. Holocain (2 per cent.) and novocain (1 or 2 per cent.) are sufficient for tonometry, and also for some operative procedures. Chloroform will have to be resorted to in operations for acute attacks. Dionin is of great assistance (3 to 5 per cent.) every one, two or three hours, as an analgesic and lymphagogue irritant, although Langenhan, prompted by his tonometic findings, cautioned against its indiscriminate use. He found it to occasionally retard the effect of the miotics. It is advisable to compress the tear-points after instillation of stronger solutions of dionin on account of its narcotic effect. The patient should be told of the severe conjunctival reaction which will set in after its application.

Darrier advises to precede the instillation of the miotics by that of dionin, the effect of which will be the more active in proportion, as it provokes a more violent reaction. Cases of acute and of noninflammatory glaucoma will be greatly, benefited, up to the time of the operation, by a 2 per cent. solution of pilocarpine hydrochlorate. In this concentration it is as effective as a one-half of 1 per cent. solution of eserine salicylate or sulphate, which usually burns or causes ciliary pain and frontal headache, accompanied, occasionally, by nausea. Where eserine, which acts more promptly in acute cases, is used, the patient should be made acquainted with its properties and his family instructed as to the danger lurking behind neglect of our orders or else the patient, afraid of the pain, will apply his drops less regularly, or not at all. A drop or two of these solutions should be instilled every hour or two.

Very effective in fulminant attacks, or in obstinate cases not ready for an operation, is the following combination of the two miotics:

R Pilocarpine hydrochlor

Eserine sulphate
Holocain

Aq. dest. ad.....

0.60 .. 0.15

0.60 ..30.00

This mixture has given splendid results, and has, for instance, tided a woman over a severe inflammatory attack, with complete absence of vision, caused by the instillation into each eye of one drop of homatropine for diagnostic purposes by another physician who failed to heed these danger signals -rainbow colors, obscurations, pain in the eyes and headache.

Iridectomy, refused by the patient at first, was performed later, and the vision restored to almost normal acuity. Stronger solutions of eserine, which commonly are given in one-third to onehalf of 1 per cent. strength, ordered in sterilized olive oil, are well borne by the eye:

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To prepare this mixture the eserine should be diluted in a sufficient quantity of ether, then the oil is added and shaken. The ether is evaporated by bringing the mixture to a temperature of 45° Celsius in a water bath.

Hot applications to the eye help in soothing to such an extent that patients often choose the continued use of a hot water bottle. Massage of the eyeball, which has been practiced in glaucoma for quite a period of time, is highly recommended in simple glaucoma, since tonometric research has proven that it quickens the absorption and increases the action of the miotics. Yet it can not be used in inflammatory glaucoma on account of the tenderness of the eyes. The effect of massage in glaucoma may be judged from the experience that the tension decreases by subsquent palpation of an eye by several examiners; for instance, during the progress of a course in ophthalmology, Schoenberg has found that the weight of the tonometer, if placed on the eye for 30 to 120 seconds, will materially decrease the tension. Fischer's subconjunctival injections of sodium citrate (4 to 5 per cent. solution) may be mentioned, but they belong into the domain of the oculist.

General therapeutic measures greatly assist the local treatment under possible consideration of the etiology of each individual case. As soon as the diagnosis is made, we must endeavor to eliminate every source of excitement from the patient's surroundings. Rest in bed is advisable, especially during an inflammatory attack. Opiates, codeine and morphine, by mouth, or even hypodermically, are indicataed in acute cases. In simple glaucoma and also in the acute form, we find large doses of sodium salicylate very efficient in reducing the tension. Small doses of iodide of potassium, in combination with a milk-vegetable diet, have yielded good results at the eye clinic of the University of Munich. Nitroglycerin has been recommended in cases of glaucoma with high blood pressure, quinine or bromides in nervous persons. Digitalis, strophanthus, or other cardiac medicines may be of assistance.

The bowels should be kept open, alkaloid or lithia waters should be prescribed. Mental anguish, being an exciting cause, must be avoided during the course of the treatment; professional worries should not be allowed to interfere. Tincture valerian (15 to 20 drops repeatedly) is of good service. Coffee, tea, alcoholic and other stimulants are contraindicated, because the rise of the blood pressure will be followed by an increase of the intraocular tension. Careful, rather bland, diet must be observed, and only small rations of meat should be

allowed. Glaucoma patients should not be kept in a dark room (Groenholm even advised to keep them in bright light), because the light will help in contracting the pupil and in re-establishing the filtration into the canal of Schlemm.

Cold and hot baths are to be forbidden because the former increase the blood pressure indirectly, the latter, directly. Stooping should be avoided; for instance, when putting on the shoes; narrow collars have to be discarded.

Here ends the duty of the general practitioner. The oculist will have to resort to operations in most every case of glaucoma. He will have to decide whether to use venesection, which has been practiced again during the last few years and is said to overshadow the effect of other local or general therapeutic means, or he will have to perform an iridectomy, or one of the more modern operations, the most promising of which appears to be corneo-scleral trephining after Elliott and Fergus.

A TREATMENT FOR DYSMENORRHEA. Dr. J. H. Carstens, who writes upon this subject for the New York State Journal of Medicine, thinks the principal cause of dysmenorrhea is the so-called infantile uterus. This organ varies in type in these cases, but usually it is of normal length but very thin-half to three-quarters of an inch in diameter. Behind this lies a wrong mode of living-often development of the mind-mental labor-at the expense of the body. In other cases of dysmenorrhea appearing later in life he finds a premature atrophy of uterus. We quote from Dr. Carstens:

"The question now is how to relieve these troublesome cases? They go to one physician, then to the other, take any quantity of medicine without relief, sometimes become dope fiends. Some practitioners say that these girls get cured when they get married, and become pregnant, and after that they have no more trouble. This is perfectly true in some cases, but how do you know that they are going to be married, and if they do, the trouble is that they do not become pregnant. This pathologic condition prevents pregnancy, and I have often been called upon to treat sterility, and find the above described condition.

"What develops muscles in any part of the body? You will all answer exercise is the only thing. They do not develop by rest. How to exercise them is the question.

"Just thirty years ago I called attention to the value of dilatation in these cases, in using a dilator twice a week and continue this for months, but few patients will continue long enough; it is too painful.

"Somehow, it occurred to me that by putting in a stem pessary that the uterus would try to expel it, and this exercise develop the organ. I began experiments with all kinds of stem pessaries. Formerly stem pessaries had been used for all kinds of displacements, but it was found that infectious trouble often resulted, and severe inflammation followed, then stems were soon tabooed, and are to this day by many. Simply because they do not select their cases, and do not understand the great principle involved. I finally selected the Chambers hard rubber pessary as the best, but always had more or less trouble with the two arms coming together, and the pessary coming out, so that I was obliged to add the Thomas-Hodge Retroversion Pessary. I finally began to use silver pessaries, which are alloyed so as to make them springy, and I know they do not come together and fall out. A so-called introducer is required to get them in place. This is painful, hence requires the use of an anesthetic. Naturally everything is supposed to be aseptic, the uterus must be thoroughly dilated to enable you to introduce the stem. The uterus can be curetted first if the mucous membrane is diseased, otherwise not. After it is in it causes no more trouble. No douches or after treatment is required. The patient stays in bed twenty-four hours, that is all. I have patients wear them for

years.

"I must warn against the use of the pessary in diseased tubes and ovaries or adhesion, etc. They must be absolutely excluded. The pessary is useful only when the condition is limited to the womb. It does not relieve dysmenorrhea caused by pus tubes, retroflexions or cirrhotic ovaries.

"Naturally, we do not always have painful menstruations alone; it is often accompanied with irregularity, coming on every six or eight weeks, very scant, and very painful. Now these cases are also relieved by the stem, menstruation becomes regular and more profuse, that is, about normal.

"Some of the most troublesome cases we have are those very fleshy women who are great eaters. The monthly flow becomes scant and painful. Here also the stem gives wonderful relief. It is wonderful how these women will lose flesh, if they become sensible and regulate their manner of living.

"Then we have those marvelous cases of reflex nervous symptoms during or between the periods, "mittelschmerz,” as the Germans call it. The kind of cases that are often overlooked.

"All I ask is for a careful selection of cases, and a fair trial, and you will seldom fail to relieve these very troublesome and often intractable cases with a silver stem pessary."

MYSTICISM AND MEDICINE. There was a time, says the editor of the Medical Brief, and not so long ago, either, when the doctor depended in no small degree upon the mystical element for his aid; the more uncanny his procedures, the greater his influence over those who came to him for medical service. It is only a comparatively few years ago that physicians made mystery a prominent factor in their work. Unfortunately even today there is still a tendency in this direction and there are many physicians who consider their knowledge uncommunicable, and under no consideration will enter into explanations of any kind to their patients.

In civilized countries we are fortunately by degrees getting farther removed from the methods of witch doctors and the influence of fetishes, although, strange to say, sone of the ideas still prevalent regarding disease and its treatment are, comparatively speaking, as crude and absurd as the strange orgies of past years about which we sometimes read and throw up ours hands in horror.

Mysticism has no place in medicine. Nowadays progressive physicians make it a point to take their patients into their confidence, explaining the circumstances and conditions as clearly as possible, and often giving a definite reason for their actions and requests. This inspires confidence in their work and the patients, with rare exceptions, follow with evident interest the progress made in their treatment from day to day.

It is unfortunate that many physicians still have the erroneous notion that their knowledge is of such a kind that it can not well be imparted to the layman. This may to a certain extent be true; we do not pretend that abstruse medical problems, which may be hazy even to the student of years, can be explained to the full satisfaction of those unlearned in medical science; but we do contend that a rough, general idea of the processes of the body that may be involved in the particular case in question, and of the raison d'etre of the treatment, are desirable in the proper handling of the majority of cases. Not that the actual remedy or combination of remedies and their dose need be disclosed, or that a morbid interest be aroused in the patient-far from it. There is such a thing as going too far and there is no such idea in our mind; but we feel, nevertheless, that there are good grounds to stimulate a greater interest in the educating factor of the general practitioner's work. The educating physician-the man who is not afraid to take a few minutes of

his time to give a reason for his action-is a constant source of valuable and helpful knowledge to his patients, and far from confusing. their minds by giving a reasonable account of his work he makes for unwavering confidence on the part of the patient, and an intelligent interest in carrying out to the letter the needful personal hygienic reforms which are essential in preventing the recurrence of the disease-conditions which may have been the means of bringing doctor and patient together.

The advantages of eliminating mysticism from medicine are not confined to the patient alone. The confidence thus inspired brings with it actual therapeutic results that are sometimes phenomenal, and the reflex benefit to the doctor who thus makes it his routine to take his patients into his confidence is evidenced in the increasing professional reputation that invariably follows work of this kind. With intelligent confidence comes intelligent co-operation-an absolute necessity in the hard struggle so often needed in the treatment of chronic conditions.

We are continually admonished in moral philosophy to "be open" "be honest"-"be above board," and we firmly believe that a little more straightforwardness and a little more frankness in medicine would have its advantages. The wise physician of today is the one who regards himself as the educator of such individuals as may come in contact with him. In explaining various matters that may come up from time to time, he safeguards their bodily interests just as the lawyer safeguards the business interests of his client. His great effort is not merely to remove the symptoms, but to protect the patient from his own errors and their unavoidable results-by education.

THE CONTINENTAL AND AMERICAN

PHYSICIAN.

In a paper by Henry L. Elsner, in the November number of the New York State Journal of Medicine, there is an interesting comparison of Continental and American physicians, as regards proficiency, from which we quote what follows:

"Personally, I feel that the continental system may be said to have some advantages because of the paternalism of the individual government, which makes it possible for the teacher to lead an independent existence, free from the cares of private practice, giving almost his entire time to the hospital, to teaching and to research. We cannot deny the fact that the interest of the student might at times be advanced in some directions if the attending physicians to our hospitals could afford

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to devote more time to the study of its material. This we could do if we were assured a competence sufficient to meet our immediate needs and were relieved of the responsibilities which rest upon us in the protection of our families.

"There are teachers of medicine in the German and Austrian Universities who devote at least three-quarters of the day to the hospital and to teaching. The incomes of these men from these sources are surprisingly large. On the other hand, is this an entirely one-sided question? I believe that our system has many advantages. The average student expects to practice along the broad highway; he comes in contact with disease in the hospital, in the homes of the wealthy, at the cotter's fireside, in the bog, in the hovel, and in his office. He needs to understand the therapy of minor ailments, of ambulatory disease as well as the most serious maladies which often fasten the victim to a mattress grave. He needs to develop that humane side of his nature, that personality which makes him the friend, the confidant, indeed the support of men, women and children in all walks of life and under all conditions.

"The limited field of the continental teacher within the walls of the hospital does not develop in the student that readiness to serve man and to treat disease, which I am fully satisfied is nurtured and sustained by the unselfish practitioner in our own country. I have cautiously observed our German colleagues in the care and treatment of their patients; their methods are usually thorough, they are slower, less keen to observe, however, than is the resourceful and practical American clinician, who spends only a part of his time in the hospital, a part in private practice, the remnant with his books, in his laboratory, and in the study of general literature.

"If the personality of the teacher is sufficiently forceful, if he has the ability to inspire his students to do thorough work; the selection of internes and assistants is made from material well trained, and there is that concert of action within the walls of the hospital, which has always characterized the relations of your own faculty to the institutions to which you have free access, making your senior year one of the application of your scientific knowledge to the art of medicine, the material within the hospitals and dispensaries will be so thoroughly studied and presented as to give you advantages equal, at least, to any which you could possibly receive within the walls of any continental institution; while you will reap added advantages because of the unlimited practice of your teachers.

"On the Continent men in the advanced classes are called during the clinic to stand by the side

of the professor and to answer an occasional question or to assist in the physical examination of the patient. These are called 'Praktikanten.' I have been present repeatedly at the clinic of a man whom I consider the highest representative living today of all that is advanced in medicine, when these men have repeatedly during their senior year shown such poor preparation and displayed such unpardonable ignorance as would chagrin and deeply mortify any conscientious teacher on this side of the ocean."

HOW TO REMOVE STAINS.

An article in the Nursing Times gives the following practical information on removing stains: Iodine-This can easily be removed by soaking it in cold water, then covering the stained part with a little powdered starch moistened with water. Spread the paste on the stain, leave it until dry and then wash in the usual way.

Medicine, such as an iron tonic-Pour a stream of boiling water over the stain, then with a bone spoon apply a little salts of lemon, rubbing it gently with the back of the spoon; pour on more boiling water and the iron stain will have disappeared. Dip the part of material from which the stain has been removed in a little water (about a cupful) containing half a teaspoonful of dissolved carbonate of soda. This is to neutralize the acid, thus rendering the effect of it quite harmless to the fabric.

Any specially difficult stain due to very strong medicine or coloring matter, which can not be taken out by the simple, quick means, can always be removed with permanganate of potash and well diluted sulphuric acid. To use these put a littlepermanganate of potash solution in a glass and a weak solution of sulphuric acid in another one, and then place the stained article in the permanganate of potash and leave it a few minutes, and this will dissolve the stain; then remove the discoloration by putting it into the weak sulphuric acid solution, and, if necessary, repeat the process until the mark is gone.

Wine stain-While wet place a paste of powdered starch (starch and cold water mixed together) on it and leave for some time (an hour or two); then rub off and the mark will have nearly gone. Finish by washing and boiling, or, if preferred, use lemon juice and common salt. Moisten the stain with the juice, apply some salt and rub with a bone spoon, using more juice if necessary; then wash in the usual way. If these simple methods fail, a weak solution of chloride of lime is always quickly successful. It can be bought in liquid form at the oil shop. Use it in the proportion of a teaspoonful to half pint of cold water.

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