As an antidote to this strong alkali, rinse the material very thoroughly in cold water. Never use chloride of lime for colored articles, or silk, as it turns white silk bright yellow, which discoloration can never be removed.

Wet ink stains-Rub with a piece of ripe to mato and then rinse well in cold water; wash and boil, or put a little red ink on the mark and wash; the acid dissolves the iron in the ink and sets free the tannin or coloring matter, which will boil out.

Tea, coffee or cocoa-Borax is best. Pour boiling water through the stain while it is wet, if possible; place some powdered borax on and pour on more water; then wash, boil and dry in the sunshine. Sunshine seldom fails in removing such stains at tea, coffee or scorch marks.

Bloodstains-These should be soaked in salt and water for some hours; then wring out and rub in a fresh supply of salt and water. Next wash in the ordinary way, with soap and warm water; boil, rinse and dry in sunshine.

THE EXCESSIVE FEAR OF CONTAGION FROM CONSUMPTIVES.

Dr. S. Adolphus Knopf, head of the department of tuberculcsis in the New York Post Graduate Medical School and Hospital, in a lecture before the German Medical Society of New York, discussed some of the unfortunate phases characterizing the present world-wide struggle against tuberculosis and again condemned, as he frequently does, the unjust and unreasonable fear of acquiring tuberculosis by the simple contact with tuberculous patients. This is a most important subject, the more so, as the "phthisiophobia"-as Dr. Knopf designates this particular craze-has attacked and led astray not only the laity, but also physicians and municipal, state and even federal authorities. In consequence, the federal law of 1901 still remains in force, under which tuberculous persons are not permitted to enter the United States, even if they desire only to pay a visit to the country, thus being placed on a par with patients ill with the plague, cholera, or other virulent infectious diseases.

The writer well understands and is fully in sympathy with the iteration and reiteration of conservative counsel in this respect on the part of Professor Knopf, and he himself has contributed here and there to the advice that saner and less extreme precautions should be taken. (For instance, see Life and Health for May, 1910.)

It may not be amiss once more to discuss this

matter and to point out to the readers of Clinical Medicine the Importance of counteracting in their clientele the unreasonable fear. that exists among so many classes in this respect. Dr. Knopf will undoubtedly be glad to furnish reprints of any of the many papers which he has written on the subject, and the writer himself has a number of copies of the journal mentioned at the disposal of the "family" for distribution among their physicians.

Although the fact that tuberculosis is infectious and can be communicated-in fact is communicated from person to person cannot be gainsaid, being firmly established since the investigations of Villemin (1864) and the discovery of the tubercle bacillus by Koch in 1882, still, the mechanism of communication is somewhat different from that of the acute infectious diseases, such as the exanthemata, diphtheria and influenza. Above all let it be remembered that a single contact with a tuberculous or consumptive person is not sufficient to establish in another person a virulent infection that invariably is followed by tuberculous disease. Indeed, it has been fully determined by wide clinical and experimental experience that not only repeated and long-continued exposure to infection, together with a receptive condition of the organism, but a predisposition is required to lead to tuberculous disease. The only exception for this rule, perhaps, is in the case of persons whose resistance to the infection and to the harmful action of the tubercle bacillus has been seriously impaired by previous diseases, such as measles, whooping-cough, typhoid fever, and influenza; by prolonged night vigils and exertion, as in taking care of a very sick member of the family besides attending to the usual duties of housekeeping; by worry, due to the same cause, or by other devitalizing influ

ences.

It remains a fact that, except in the case of such a serious impairment of the resistance, a single or even several repeated exposures will not suffice to determine an infection productive of disease.

Early in the eighties Professor Straus, in Paris, found that the medical students and internes as well as visitors to his hospital and especially to the consumption wards harbored in the mucus of their nares large numbers of tubercle bacilli that proved virulent upon inoculation into cavies. These students and internes of course were exposed to contact infection with reasonable frequency, and, yet, owing to an efficient resistance, also to the fact that

they were obliged to be in the open air more or less, as well as to other factors, not one of them acquired tuberculosis.

Furthermore, it is a well-known phenomenon that physicians and nurses, even if they exclusively care for consumptive patients, very rarely acquire the disease, not because this is not contagious, but because ordinarily adults are sufficiently resistant to be able to overcome the results of an exposure to this infection.

It is true that in the case of children, and especially of infants, conditions are not quite as favorable and that the little ones are all too frequently infected by consumptive attendants, whether they be brother or sister or mother or nurse-girl. Yet, even in such cases the infection need not necessarily lead to an immediate disease, but may remain latent until puberty, when a superimposed infection or a weakening of the organism through undue exertion or through disease may arouse the latent infection to a virulent progression.

There are other reasons why at the present time the contact with consumptives, at least with such as have received the benefit of expert advice and have the good sense to follow it, is not necessarily dangerous. These patients are informed that they may become a source of danger to those with whom they live if they are not careful in regard to their expectorations. They are taught never to breathe or sputter.or talk into the faces of other persons, always to cover their mouths with a cloth or a bit of tissue paper when coughing and these to be burned afterward. always to wash their hands if these have become contaminated with sputum, and in other ways to do all in their power to avoid communicating the germ of their own disease to others.

Of course, it is only the careful consumptive and the tuberculous patient whose sputum does not contain tubercle bacilli who is not a source of danger. The careless and inconsiderate, promiscuous spitter is a criminal who needlessly endangers the life and health of his neighbors and should be isolated in an institution, while the advanced, progressive, bed-ridden consumptive who is too feeble and ill properly to take care of his expectoration is isolated eo ipso and must be taken care of as any other patient suffering from an infectious disease.

As a whole, we may safely assure our patients and their sisters and cousins and aunts that there is comparatively little danger of contact infection from tuberculous patients, that efficient care on their part and a proper hygienic mode of life on the part of the well will both

prevent infection and render it innocuous if it should be unavoidable.

TREATMENT OF THREATENED ABORTION.

From the many excellent papers submitted to the prize contest of the New York Medical Journal. on the subject of abortion, we select that of Dr. Alfred Costales for reproduction in the Medical Standard. He says:

When called to attend a case of threatened abortion, after satisfying ourselves that the patient is really pregnant, as ascertained by the history obtained, and by a very careful and complete physical examination, at the same time noting the probable duration of gestation-we order the patient to bed, keep her in the recumbent position, and proceed as follows: Washing and scrubbing the hands and arms. with soap and hot water, carefully disinfecting the same with bichloride solution, one in 2,000, or alcohol full strength, touching the ends of the fingers with tincture of iodine and smearing the fingers and the whole hand thoroughly with some antiseptic lubricant, we make a vaginal examination and feel the condition of the os uteri and cervix.

If the os is found undilated and the cervical canal unexpanded, the hemorrhage being slight and the pains controllable, we have to deal with a threatened abortion and recommended absolute rest in bed, forbidding all excitement, etc. The indications are to arrest the further progress of the case by giving the patient a hypodermic injection of morphine, 14 grain, and atropine, 1/150 grain; or pulveris opii, 4 grain, and gallie acid, three grains, every three hours, for a few doses only, to arrest hemorrhage and pain; or one drachm of the compound tincture of viburnum opulus (National Formulary) every two or three hours. In the majority of the cases we will not succeed because the patients will not carry out our orders, as in the present epoch they prefer to get rid of it.

If the case becomes one of unavoidable abortion, as indicated by a dilated os, profuse hemorrhage accompanied by sharp uterine pains, and the os and cervix are dilated enough to admit one or two fingers, we at once proceed to evacuate the uterine cavity by peeling off the membranes and removing the entire uterine contents, making downward counter pressure on the uterus through the brim of the pelvis, with the other disengaged hand, so that it will be helpful in our manipulations; or we can introduce an irrigating curette properly sterilized, and remove all rough surfaces found therein by gently curetting and using at the same time a

hot intrauterine bichloride douche, one in 5,000 at about 115° F., or using the tincture of iodine one drachm, to the quart of hot water. If necessary, we may bring down the uterus with à forceps or a tenaculum, thus facilitating our purpose. Give the patient one dram of fluid extract of ergot, every three hours, for a few doses.

If the os and cervix are not dilated, we must have recourse to dilatation by mechanical means, as follows: After introducing a large vaginal speculum and locating the os and cervix, we insert Hegar dilators in succession, or use any good cervical dilator and gradually dilate the canal until it is large enough to admit of packing, say one quarter of an inch or more. We then pack the cervix and vagina with long strips of iodoform or other antiseptic gauze or, if preferred, we may insert, to advantage, a medium or a large sponge or tupelo tent instead, which will have the effect of at once arresting the hemorrhage, however severe, and in from four to six hours we will find either the fetus expelled into the vagina, or the cervical canal so pervious that operative measures are at once available, either with the fingers (always to be preferred) or with the curette. A correct procedure in these cases, where hemorrhage is alarming and the cervix undilated or nearly so, would be to call an assistant, anesthetize the patient, and proceed at once by manual dilatation to evacuate the womb, using an abundance of sterilized lubricant for the hands, which will greatly facilitate the operation, never forgetting to use the hot antiseptic douche of bichloride, or the tincture of iodine, as mentioned, and, if need be, a hypodermic injection of ergotin, thus: R Ergotini.

FRACTURE ABOUT THE ELBOW. The X-ray has become almost indispensable, says Dr. W. D. Haines, in the Lancet-Clinic, in the diagnosis of fractures, about which he gives some very interesting and helpful points. Fracture of the olecranon is the most frequent variety near the elbow joint. Fortunately it is usually a clean break. Tilting of the upper fragment is caused by an uneven tearing of the expanded portion of the triceps attachment, and there is a tendency to rotation which is hard to overcome.

One of the chief symptoms of fracture of the olecranon process pertains to the patient's inability to fully extend the arm. This function may be partially or wholly lost, depending upon the damage which the ligament has suffered. Do not be deceived by gravity extension; by fixing the forearm, ask the patient to extend it while the examiner resists the attempt. Palpation will reveal the line of cleavage when this is perceptible, and when it is not to be felt tenderness may be elicited by pressure over the line of the break. This examination will reveal the above features best if the patient's forearm is fully flexed, but in seeking crepitus better results will be had with the forearm fully extended during the examination.

Our results have been so favorable in the treatment of fracture of the olecranon by the straight, anterior, long, shoulder-to-wrist splint that we continue to employ and commend this form of dressing. There is in the vast majority of this type of fractures but a slight degree of separation of the fragments. Surely, nothing is to be gained by subjecting such a case to operation. In some cases in which the fragments are widely separated, the deformity may be overcome by the use of morphia, hot bath and massage, the arm dressed in full extension and displacement of fragments prevented by the application of adhesive strips. We are assured by the pathologist that ligamentous union is the most we may hope for by this method, that the union will stretch when subjected to severe muscular strain and impair the function of the forearm. If operation is to be performed it were better done at once, as early operation gives much better results, in that one does not have to contend with shortened muscles and undo the previous efforts at bone repair and call for a repetition of the reparative processes. If operation can not be performed on the day of the accident, better results will follow the application of heat and massage for ten days preceding the operation, at which time the lymph and blood clots

will be partially organized and the local resistance to germ invasion at the time of operation will be increased. Practical experience proves this practice, but the explanation may or may not be correct. With the field well exposed by an incision so placed as will do least damage to the ligaments, blood vessels and nerves, the clots are thoroughly removed by the use of gauze, hot salt solution and curette. The fragments are drilled and a piece of kangaroo tendon is drawn through the holes, and, by placing the arm in full extension, the fragments may be readily brought in close relation and secured by tying the ligature. Suturing the torn triceps attachment has always seemed to the writer to be of didactic rather than practical import.

The arm should be placed at rest for two weeks, at which time light passive motion may be begun and light exercise at the end of six weeks. Heavy work should not be undertaken by the patient under two months from the time of operation.

Dr. Hanies commends the operation in all open fractures of the olecranon, and in those cases wherein the fragments can not otherwise be kept in close apposition.

A FAMILIAR FORM OF CYSTITIS. There is a form of cystitis quite familiar to the general practitioner. It occurs in females, old and young, with apparently normal pelvic organs, generally after a chilling. There is an abrupt onset with frequent micturition, tenesmus, and perhaps dysuria. The acid urine contains the infecting organism, usually a colon bacillus, pus, and often blood. Rest in bed, local warmth, light diet, free catharsis and sanmetto are the measures employed, and in a few days the severity of the attack subsides, and generally in two or three weeks the patients are as well as

ever.

A New Plan at Johns Hopkins.-The General Education Board, founded by John D. Rockefeller, has provided the Johns Hopkins Medical School with a bequest of $1,500,000 with which to undertake a new venture in medical instruction. Hereafter the professors of medicine, surgery, gynecology and obstetries, the so-called practical branches, will be placed upon salaries and will be pledged to devote their entire time to the university work. They will be permitted to treat outside patients, but not for private fees. It is expected that this arrangement will still further raise the standard of clinical teaching at Johns Hopkins, the staff being free to devote their efforts to the hospital work. It will, of course, involve considerable

sacrifice to some of these great teachers; but that it will eliminate the objectionable advertising feature of a university professorship, and add to the value and thoroughness of instruction, there seems little doubt. We hardly think, however, that such a plan would "go" in Chicago. There are still far too many little professorial hatchets to be ground here.

The von Pirquet Test. The von Pirquet skintest for tuberculosis is declared by F. H. Smith (Charlotte Med. Jour., Feb., 1913, p. 85) to be entirely harmless. The local complaint is of a trivial character, while no general reaction has ever been provoked by it; also, it is simple, inexpensive, and can be made by any physician. Out of 42 cases reported in which the reaction was sought, there were 16.66 per cent demonstrable cases of tuberculosis in which the reaction was not obtained. On the whole, Dr. Smith states that the von Pirquet reaction has been helpful to him in 76 per cent, and confusing in 24.

Yeast in the Treatment of Vaginitis.-Since the acid secretion of the vagina affords the most certain protection against infections, the clinical should be careful to promote this, rather than to destroy it by alkaline douches. The acid reaction of the vaginal secretions is the result of

biologic processes. Since sugar offers an excellent medium in this respect, because it renders many germs, especially the usual inhabitants of the vagina, productive of acid, the sugar which is introduced in the yeast-treatment of vaginitis performs a useful purpose. In like manner the glycerin-treatment of this distressing condition is according to F. Kuhn (Centralblatt f. Gynaekologie, Bd?37. 1913. S. 228) of value because in the cleavage of the glycerin molecules acid products are likewise formed.

Little Pat and big Mike had had a dispute, when Mike in contempt said: "Ye little runt, Oi bet I could carry yez up to the fifth story in me hod."

Pat immediately took up the bet, saying: "I'd loike to see ye thry thot same. I'll bet yez fifty

eints on it."

Before he knew it, Mike had him in his hod and was going up the ladder. When he got to the fourth story his foot slipped and he almost fell. He regained his footing, however, and reached the fifth story in triumph.

"Oi win!'' he said.

"Yez did thot," said Pat, "but Oi had high hopes when yer foot slipped."

EXPECTORANTS.

This being the time of year at which the average physician is more interested in the cure of colds, coughs and bronchitis than anything else, we thought it advisable to have a discussion of the subject of expectorants and similar remedies for the control of these conditions.

Expectorants are usually roughly divided into two general classes. First, those which are nauseant and depressant. Second, those which are stimulants both of the circulation and of the excretion of mucus.

The depressant or nauseant expectorants are given to cause relaxation of the capillaries, and especially those of the bronchi, permitting of a freer flow of blood to the parts and freer secretion of mucus, at the same time causing diaphoresis, bringing the blood to the surface of the body and facilitating its more equable distribution and thereby relieving respiratory congestion. The principal remedies of this class are ipecac, apomorphine, tartar emetic and lobelia.

The remedies which stimulate expectoration include principally the ammonium salts, which also probably have the effect of liquefying the sputum and rendering it more easy to raise. Potassium iodide also liquefies the sputum, but is rarely given at the early stage of these diseases, usually being reserved for the delayed cases, those in which there is considerable tenacious sputum which is raised with difficulty. Other remedies which stimulate expectoration are senega, squill and sanguinaria. These are reserved mainly for cases in which the secretion is rather profuse but is raised with considerable difficulty, especially when there is debility or senility. These remedies are not to be used ordinarily in the acute stages of respiratory catarrhs, but rather in the late stage.

Still another class of remedies which is of considerable value are the antiseptics. Belong

ing to this class are practically all of the balsams, benzoins, turpentine, terebene, creosote, guaiacol and iodine and its preparations. These undoubtedly have some action upon the bacterial flora and are of greatest value in the more advanced stages when there is still considerable expectoration-with the possible exception of iodine, which seems to be useful at almost any stage.

Still another class of remedies includes those used to dry up secretion. Their employment is restricted mainly to capillary bronchitis occurring in children in which it is necessary to limit the amount of mucus to prevent the child from being "drowned in its own secretions." Belladonna and hyoscyamus and their alkaloids are the principal remedies of this class.

To check cough, opium and its alkaloids and derivatives are most employed. However, in mild cases sufficient sedation may be obtained by the use of such remedies as menthol, cannabis indica and chloroform; or by the use of emollients such as licorice, flaxseed, Irish moss, and the like.

These different remedies are variously combined to meet special indications which may be present in any instance.

With this introduction we will permit our contributors to tell their experiences.

Dr. Albert F. Fuchs, Loyal, Wis., says that his favorite nauseating expectorant is wine of ipecac and he uses this particularly in treating children. He never uses apomorphine as an expectorant. He tried it in two cases of capillary bronchitis in adults some thirty years ago and in both instances bad symptoms followed. Stimulants such as whiskey and ammonium carbonate brought about a reaction in one case five days later, with profuse expectoration and recovery.

To break up a cold, Dr. Fuchs' favorite remedy is a full dose of Dover's powder with plenty of hot lemonade, putting the patient to bed.