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different cavities of the heart, but I have failed to discover any constant or general law.

One kind of reflected pain is sometimes met with in connection with left ventricle distension or failure, which deserves mention, viz., great cutaneous hyperaesthesia. This may affect the whole praecordial region, and some distance around it, and it may be so acute that the slightest touch produces exquisite distress, and percussion is impossible. A somewhat similar condition may be met with occasionally where there is acute pericarditis. It is then attributed to direct irritation of the branches of the intercostal nerves, but I have never seen it so pronounced as in the left ventricle cases I have mentioned. As in these there is no question of pericarditis, it must then be regarded as indirect and reflected. This condition is easily dealt with, for brushing the parts over freely with tincture of aconite quickly allays it, and, once removed, it does not ordinarily recur.

WOUNDS OF THE FINGER-ENDS. Guibe (Monde Médical) says that wounds of the finger-ends are very frequent, but usually badly treated. In mutilations, when the tip is completely severed, spontaneous cure is very slow. If the bone is uncovered, the projecting portion is detached only after a long time, through a process of ostitis lasting for weeks. Cicatrization once made, the skin of the new formation is fragile, thin, liable to ulceration, and many times quite painfully sensitive.

The cure is speedy in contused wounds. The nail falls off in a short while, a new nail form ing under it, often irregular and deformed; still, all is repaired, whether well or badly done.

In wounds at the joint, if these do not contain enough uninjured vessels, necrosis follows and cicatrization occurs slowly, as in mutilations. At other times, if the surfaces are not well held in contact and in the right position, there is a luxation of the loose phalanx and between the surfaces a bloody mass forms that hinders healing. This follows in time, but the finger-end is deformed.

Diverse complications may occur (infectious, etc.), varying with the cause of the injury. There may be lymphangitis, phlegmons, suppuration of the tendinous sheaths (rare), and sometimes even tetanus may develop.

Treatment: First wash and carefully arrange the fragments, remove foreign bodies, and, if the wound has been soiled by manure or elsewise, inject antitetanic serum. If the wound is clean-cut and without soiling, this is unnecessary.

Sometimes the end of the finger has been cut

off and the patient has brought it to the surgeon. Should it be replaced? That this may have a chance of success, it is necessary that the wound be recent, very fresh, and the severed end clean-cut, not contused, lacerated or infected. Under these conditions, one may essay the graft.

Having washed the tips with lukewarm serum, and also stopped the bleeding, apply the severed piece carefully to the stump and fix it with four sutures. Then wait results, examining the finger frequently. If the detached piece dies, blackens, and especially if it suppurates, the attempt is sure to fail and one better remove the tip.

To facilitate the cure, many processes have been employed. Some have attempted to use Bier's hyperemia to draw arterial blood to the graft and to disgorge the veins. When the color of the graft shows that circulation is established, the apparatus may be removed. Leeches have been applied also to the sound part of the member; thanks to the local hemophilia and incoagulability developed from the bite of the leech, the local circulation re-establishes itself more readily. Also, to cover over the wound, one may resort to the Thiersch grafts.

More promising than either of these methods is the application to the wound of nuclein. Frankly, were this to fail, the graft might as well be removed at once, thus saving time and allowing proper measures to be instituted without delay. Guibe acknowledges that his attempts have not met with the slightest success.

When the severed end is held by a pedicle that is not devitalized, do not hesitate to suture it in place.

When restoration of the severed end is not to be considered, re-arrange the lacerated tissues, disinfect with tincture of iodine and remove any remnants of the nail. Anesthetize the region with novocain solution, 1⁄2 per cent (or, better, with anesthaine). Detach and remove the nail, then, with a bistoury, incise circularly the soft parts to the bone, some millimeters from the traumatized parts, avoiding reaction; then sever the bone. If the cut has been skilfully made, the lips of the wound will join readily; if not, remove a little more bone. Assure hemostasis, if necessary, by ligating the collaterals. Now unite the flaps by sutures passed far enough from the edges. Generally, healing is by first intention, the finger shortened, but with a linear resistant cicatrix.

In simple wounds of the soft parts, asepticize with tincture of iodine; trim the bleeding surfaces, cut away the debris of tissues sure to necrose, pick out any soiled bony bits, then suture the restored ends.

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THE DOCTOR'S DREAM; OR WHAT MIGHT BE ACCOMPLISHED BY PREVENTIVE MEDICINE.

Here is the story of a dream of a busy doctor, after a hard day's work, when he had seen something of the terrible results of ignorance, carelessness, over-strain, neglect and vice. The story is told by Dr. Victor C. Vaughan, in an address given before a group of life insurance company presidents. We quote it in part only:

"On a certain November day Dr. Smith had been unusually busy. Late that night as the doctor sat before his grate he fell asleep, and now he is busy among his patients in a way hitherto quite unknown to him. His waiting room is filled with people, old and young, of both sexes, who have come to be examined in order to ascertain the exact condition of their health. A young man before proposing marriage to the woman of his choice wishes a thorough examination. He wishes to know that in offering himself he is not bringing to the woman any harm. He desires to become the father of healthy children and he is not willing to transmit any serious defect to them. He tells the doctor to examine him as carefully as he would were he applying for a large amount of life insurance. The doctor goes through the most thorough physical examination and tests the secretions and blood with the utmost care. He understands his own responsibility in the matter and appreciates the high sense of honor displayed by his patient. A young woman for like reasons has delayed her final answer to the man who has asked her hand in order that the doctor might pass upon her case.

"Here is the doctor's old friend, William Stone. Mr. Stone is in the early fifties. He has been a highly successful, honorable business man, has accumulated a sufficiency and enjoys the good things which his wife prepares for the table. A careful examination of the urine leads the doctor to caution Mr. Stone to reduce the carbohydrates in his food. Mr. Perkins, a lawyer who throws his whole strength in every case he tries, and of late has found himself easily ir

ritated, shows increased urinary secretion and a blood pressure rather high. A vacation with light exercise and more rest is the preventive prescription which he receives. Mrs. Williams, after being examined by Dr. Smith, undergoes a slight operation under local anesthesia, and is relieved of the first and only malignant cells found in her breast. Richard Roe, who is preparing for a long journey, is vaccinated against typhoid fever, a disease no longer existent in Dr. Smith's city, since pollution of the water has been discontinued. John Doe, who is a mineralogical expert and wishes to do some prospecting in high altitudes, has his heart examined.

"There are numerous applicants for pulmonary examination. This is done by Dr. Smith and his assistants in a most thorough and up-to-date manner, and advice is given each according to the findings. It has been many years since Dr. Smith has seen an advanced case of pulmonary tuberculosis, and the great white plague will soon be a thing of the past. Everybody goes to a physician twice a year and undergoes a thorough examination. The result of this examination is stated in a permanent record, and no two consecutive examinations are made by the same physician in order that a condition overlooked by one may be detected by another. Cases of doubt or in which there is difference of opinion are referred to special boards.

"The average of human life has been greatly increased and the sum of human suffering has been greatly decreased. Preventive has largely replaced curative medicine. Tenements are no longer known; prostitution and with it the venereal diseases have disappeared; institutions for the feeble-minded are no longer needed, because the breed has died out; insanity is rapidly decreasing, because its chief progenitors, alcoholism and syphilis, have been suppressed. These and many other pleasing visions come to Dr. Smith in his dream, from which he is startled by the ring of the telephone at his elbow. The call says: 'Come quickly to Pat Ryan's saloon at the corner of Myrtle and Second. There has been a drunken row. Bring your surgical instruments.' Then the smiles which had played over the face of the doctor in his dream were displaced by lines of care, and he went forth into the darkness of ignorance and crime."

It has been proposed that the life insurance companies represented here seek to prolong the lives of their policy holders by offering them free medical re-examination at stateù intervals. It has been shown that in all probability this would financially benefit the companies in the increased longevity of their policyholders and the increased number of premiums they would pay.

This is a business proposition, and I hope that the companies will inaugurate it and thus demonstrate that the lessening of sickness and the deferring of death will pay. Let the insurance men join the doctors and help in the great work for the uplift of the race through the eradication of unnecessary disease and premature death. In this way we can hasten the coming of the better man by making the doctor's dream a reality. I am confident that you will do this, not because it will pay, but because it is the highest service you can render humanity.

Now, is this a wild dream?

Is it absolutely impossible that part of this dream might not come true?

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TRAUMATIC HYSTERIA.

Just to illustrate the power of suggestion to cause (or simulate) disease we reproduce from Colorado Medicine the report of a case of traumatic hysteria, as given by Dr. Edward Delehanty.

The patient was a young woman who was thrown from her carriage in a collision with a wagon belonging to a wealthy corporation. At first she felt no inconvenience except the general shock, but accompanied her mother (who was also injured) to a hospital. For three months she was able to work, but suffered at times with pain in her back. She finally consulted a physician, who examined her back, also testing her legs for anesthesia and loss of power. At that time there was no evidence of cord involvement, but in the course of a week she became completely paralyzed in the legs. It was not long until her arms became involved, and finally the special senses. She lost the use of her voice and had difficulty in deglutition so that it was necessary to resort to rectal feeding.

For three months she lay in bed, completely paralyzed. During this time a damage suit was being instituted against the company for $25,000. She was brought to Denver on a stretcher to attend the trial. She was taken to a hospital and at the request of the defendant I made an examination. She was pale and anaemic, and bore the appearance of having passed through a long siege of sickness.

There was complete paralysis of legs and arms. Anesthesia was complete to all forms of sensation except about the anal and genital regions, where sensation was present, but diminished. Unexpected jabbing of needles into her body caused no expression of pain on her face. Her body could have been made a veritable pin cushion without any remonstrance from the patient.

The knee jerks were increased, but equal. There was no Babinski, Oppenheim or Gordon

reflex. Superficial reflexes were absent. She had perfect control over her bladder and bowels.

Her pupils were widely dilated but responded to light and accommodation. The response, however, was not well sustained. An electrical examination disclosed no reaction of degeneration in any of the different groups of muscles.

While in the hospital, Delehanty gave a clinic on her to a body of medical students and in her presence explained that there was no known organic disease of the nervous system that could give rise to the condition she presented, and that it was a pure case of traumatic hysteria.

The effects of the clinic seemed to have produced a profound impression on her mind, for on the next day she was able to move her extremities and take her food through the natural channel.

The paralysis, anesthesia and the aphonia had almost entirely disappeared before she was aware of the results of the trial.

An indulgent jury awarded her some $6,000 as balm for her fancied injuries. In less than a week's time after entering the hospital on a stretcher she was able to walk about and left with her physician for her home in the mountains.

"I have been advised," said S. Delehanty, "that she has never been the same as before the accident.' Here suggestion was supplied, unconsciously, no doubt, by her family physician. Each examination which he made suggested new symptoms, which later appeared, and when she became completely paralyzed he hypnotized himself into the belief that her condition was due to some obscure degeneration in the columns of the cord, for under oath he testified that she would never be able to walk and probably would not live a year."'

Litigants of this class usually look to the family physician to support them in their fight against heartless corporations, and court records show that they are seldom disappointed.

The best service which could have been rendered this girl would have been plain speaking very early in the case. Had she been taught to turn a deaf ear to her distorted sensations, been discouraged in her desire to obtain revenge and reward by instituting a damage suit, she would have been saved much pain and anxiety, and avoided the demoralizing effect, which invariably follows in the train of damage suits.

To Prevent Mosquito Bites.-Acetic ether, 10 grams; tincture of eucalytus, 20 grams; tincture of pyrethrum, essence of mint, of each 60 grams; water, enough to make 1 liter. Label: Apply as a lotion, to prevent the attacks of insects.

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THE BUTTERMILK GERMS.

While buttermilk has been used as a food for centuries, and in all kinds of forms, only within recent years has it been suggested as a medicine. Such use of the lactic-acid bacilli really dates from Metchnikoff's adaptation of Massol's discovery of the Bulgarian germ, which differs from other similar organisms (1) in its power to produce a very large quantity of the lactic acid, and (2) in its extreme viability when in contact with other germs, which, in the main, it has the power of "overriding" when in contact therewith. Metehnikoff popularized this micro-organism with astounding rapidity-thanks to his suggestion that it had the power of producing long life. The Bulgars were aserted to be peculiarly prone to remain a long time on this troublesome sphere, and the fact that they used Bulgarian (Massol-germ produced) buttermilk as a beverage was asserted to be the cause.

While the claims at first made for the lacticacid germs were undoubtedly extravagant, in later years we have been learning that they are capable of doing good in a variety of diseases. In addition to their direct action upon various morbid conditions of the alimentary canal-diarrheas, colitis, and the like-we are finding them of value in diseases only remotely referable to disturbance in this portion of the body. For instance, Beveredge and Boston are reporting excellent results following the use of Bulgarian bacilli in diabetes, and recently a southern physician, through the columns of the Journal of the American Medical Association, declares he has obtained good results with them in treating pell

agra.

Of special interest is Dr. Wood's report (given below) of the use of sour milk and ordinary sourmilk germs in the local treatment of diphtheria and diphtheria carriers. We recommend that this be given very careful consideration.

The subject is a very interesting one, and we sincerely hope a perusal of the papers that follows may elicit further discussion.

Dr. Harold B. Wood, Providence, Rhode Island, says that because the germs of sour milk are useful therapeutically, buttermilk can scarcely be claimed, a priori, to be a valuable food for normal constitutions. In certain intestinal infections or fermentations it may be used to change the existing flora. The palatableness of buttermilk, as with castor oil, is relative. Dr. Wood doubts if all people can be made to enjoy it. The Bulgarian buttermilk may or may not be as objectionable as other makes. He has never used the Bulgarian bacillus, his work having been with diphtheria cases and carriers, in which a concentrated spray of the bacillus lactici acidi, isolated from ordinary sour milk, was used. preparing the spray a two to four day culture of the organism is washed off by agitation with sterile normal salt solution; this is diluted to an opaque, heavy suspension, and used in a sterile atomizer. Spraying of the throat may be done several times daily. Since lactic-acid germs in themselves are nonpathogenic it seems safe to apply them to mucous surfaces. Dr. Wood has learned of no contraindications; however, he would hesitate to use them in gastric hyperacidity not bacterial in origin, and also in inflammation of the ureters.

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Dr. Wood says that in its influence upon intestinal conditions he would classify the lacticacid bacillus not as an antiseptic but as an overrider which, by its excessive growth and production of acidity checks and prevents the development of other bacilli. Its usefulness is, therefore, limited to those cases in which it comes in direct contact with the infecting pathogens. He has had no experience with these organisms in the treatment of typhoid fever, but he would be willing to prescribe sour milk in early cases of this disease. In the diarrheas he thinks lactic-acid bacilli will have more usefulness in acute than in chronic or mucous colitic conditions.

In diphtheria cases, Dr. Wood says that he has used sprays of the ordinary brew of lactic-acid

bacilli when membranes were present in the throat; also in convalescents and in diphtheria carriers. In each case there was rapid and marked improvement with almost immediate disappearance of all diphtheria bacilli and of subsequent infectiousness. As a result of this he recommended (in the Journal of the American Medical Association) the use of douches of ordinary sour milk. Excellent results with this method were soon reported by Michael and later by Nicholson, Wessinger, and others. The sour milk is not a substitute for antitoxin but should be used as an adjuvant and for clearing up the parts infected with diphtheria bacilli. In diphtheria with asthma, where anaphylaxis is almost certain to result from using antitoxin, the sour milk and lactic-acid bacillus should constitute the only treatment.

Dr. J. F. Biehn, Chicago, writes that, in his opinion, the principal advantages possessed by buttermilk over ordinary sweet milk are: first, in buttermilk the casein has been precipitated and the curd being very fine, a much greater amount of surface is presented to the gastric juices. Digestion is, therefore, necessarily much more rapid, as a result of which the large curdy masses are not formed, which are either so irritating to the stomach as to cause vomiting, or are so large that they pass through the entire gastrointestinal canal without being completely digested. Further, buttermilk does not usually contain the many varieties of bacteria, some of them harmful, that are found in ordinary milk, while the bacteria which sour milk rapidly drive out the other bacteria, as a result of the production of lactic acid.

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Doctor Biehn states that he experiences no difficulty whatsoever in preparing bacillus Bulgaricus buttermilk. He proceeds as follows; One quart of milk is boiled, and then allowed to cool to a temperature of 115° F. It is then inoculated, either with bacillus Bulgaricus tablets, or a bouillon culture, and set aside, either in the incubator or in a fireless cooker, for eighteen hours. If at the end of twelve hours, the temperature in the fireless cooker has fallen below 98° F., the milk is again heated to a temperature of 115° F. At times it may require as long as twenty-four hours for sufficient coagulation to take place. The milk is then thoroughly stirred, to make it homogeneous (although there should be little or not separation of whey) and set on ice. Occasionally the bacillus Bulgaricus will produce ropy milk. This is one of the definite characteristics of the organism, and aside from its appearance, there is no objection to the ropy form. A temperature of 110° to 115° is absolutely essential.

The doctor uses the bacillus Bulgaricus either in the form of fresh tablets, or in bouillon. Ordinarily he administers five to 10 Cc. of bouillon one-half hour after the breakfast, which is the principal starchy meal of the day. When tablets are used, six to ten tablets are administered three times a day. This dose is maintained until there is marked evidence of improvement and the indican has disappeared from the urine, this usually requiring from a week to ten daysrarely two weeks. The treatment is then discontinued for a week, after which it is again instituted for a week or ten days.

For local application, Doctor Biehn uses the bouillon in full strength, and also the tablets, crushed, as a powder, without any diluent what

ever.

Up to the present he has not found any contraindications to the use of bacillus Bulgaricus, nor has he seen any mentioned in the literature.

Doctor Biehn has found the bacillus Bulgaricus to be an efficient intestinal antiseptic, at least in so far as it prevents putrefaction, making conditions unfavorable for the growth of anaerobic putrefactive bacteria. Whether this action is due to the lactic acid which this organism produces (it produces on an average of four per cent of lactic acid), or whether it is due to some other cause, he is not able to state.

He has not used the bacillus Bulgaricus in the treatment of typhoid fever, except for the avowed purpose of preventing putrefaction in cases which showed a marked fetor of the stools. He employs bacterins in the treatment of typhoid fever, and has practically no failures with this method, combining it with the ordinary remedial meas

ures.

The doctor states that all cases of infantile gastroenteritis and bacillary diarrhea are amenable to bacillus Bulgaricus treatment. In children he administers calomel or castor oil as an initial purge, after which he gives either the bouillon, with milk sugar or in the regular food, or the tablets. In these cases the bacillus Bulgaricus, either in bouillon or tablet form, is given every two to four hours. Practically the only cases in which a cure is not noted are those developing an intractable condition of malnutrition. Formerly the milk diet was not maintained, but now the regular diet of the child, provided the child has been gaining weight on it before the illness, is continued during treatment with the bacillus Bulgaricus.

Doctor Biehn has also employed the bacillus Bulgaricus and found it efficient in several cases of mucous colitis, in combination with boldine, although most of these cases require from three to six months' active treatment. He has found

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