method of putting a sick lung at rest in all unilateral cases. Another error is the use of ergot in hemorrhage, tending to increase the blood pressure, and the administration of normal salt solution in exsanguined cases, thus again distending the vessels and opening up their lesions. The patient is most likely to survive a large lung hemorrhage when the blood pressure of the parts is lessened to the utmost for the time. Still other errors are the recommendation of indiscriminate eating taxing the digestive powers, errors of clothing, the injudicious recommendation of change of climate. In Illinois, patients, by proper management, can be given 85 per cent, of the benefits of the very best climates. With the modern treatment of the disease properly carried out, in almost any climate its mortality can be reduced another 10 per cent., and this he maintains will be effected.

ABDOMINAL TUBERCULOSIS.-W. J. Mayo, Rochester, Minn., from his extensive experience with abdominal operations, of which about 3 per cent, were due to some form of tuberculosis, finds that tuberculosis peritonitis is much more frequent in females than in males, and that the explanation of this fact may be found in the frequency of tubal infection (Journal A. M. A., April 15). He has verified Murphy's observation of the patency and thickening of the tubes on one or both sides in these cases. In nearly all the peritoneal involvement was greatest near the infected tube, and this he attributes to proximity and not to gravity, as has generally been done. He explains the curative effect of laparotomy in these cases as acting in two ways: First, by the mechanical separation of the fimbriated extremity of the tube from the surrounding tissue; and second, after removal of the fluid, contact and adhesions with neighboring structures may wall off the infection from the general peritoneal cavity and enable nature to exert itself on a limited focus and to produce a cure. In some cases he has found appendiceal and not tubal infection as the cause. In the majority of cases, however, the localized focus of lupus of the tubal mucosa was the cause. He holds that the failure of laparotomy and evacuation of fluid in tuberculous peritonitis is due to reinfection from local lesions not removed, and in the mucosa of the fallopian tube, appendix or intestinal tract. In nearly every case the peritonitis has its origin in a local focus, pri

mary or secondary, and, if the former, radical operation will largely increase the chances of its cure.

APPENDICITIS.-Channing W. Barrett, Chicago (Journal A. M. A., April 15), has analyzed the vital statistics of Chicago for the last fourteen years with special reference to appendicitis. He finds that it causes about I per cent. of the mortality from all causes. The first consideration is an early diagnosis. All troublesome appendices should be removed without waiting for an acute attack, and all acute cases should be operated on without waiting for pus. rupture, adhesions or a possibe interval. Perforation or gangrene with localized abscess should be operated on with drainage or removal of the appendix, according to the judgment of the operator, and operation is the more necessary if there is no walling off of the abscess. Acute appendicitis should be operated on whenever the patient's condition permits, unless he is clearly convalescing. In that case wait till the acute symptoms are over. Healthy appendices should be left alone. The above counsel does not contraindicate rest, stomach lacage or the withholding of food, any of which measures can be employed as needed with or without operation. Lastly, life is not the only question; time and after conditions are also important. Adhesions may be temporarily life-saving and later deadly. The waiting treatment favors them. After operation the patient is usualy up in from ten days to three weeks. The rest treatment takes a much longer period of time.

DIPHTHERIA INFECTION IN MINNESOTA.-F. F. Wesbrook, Minneapolis, Director of the Minnesota State Board of Health (Journal A. M. A., March 25), describes the methods of handling diphtheria epidemics in that state. The principal points insisted on are the needs of thorough laboratory examinations, repeated frequently if necessary where suspicious bacilli are found, isolation of cases and of hitherto unaffected individuals with simple sore throat and prompt executive action based on laboratory experts. After the system is well started, competent local medical authorities can be relied on, if sufficiently impressed with its importance. The experience in Minnesota has shown that this is perfectly practicable under most varying conditions, and this is proved by the history of the management of epidemics given in the paper. The experience of Minnesota seems to point to the

conclusion that diphtheria infection is usually transmitted by almost direct exchange of the flora of the nose and throat.

stitutional and school life the more independent the individual and the easier the individual isolation, the less is the diphtheria infection and the easier is its eradication.

THE ETHYLS IN GENERAL ANESTHESIA.

In a paper read before the Columbus Academy of Medicine, Dr. Goodman reported some original investigation in reference to "The Ethyls in General Anesthesia," published in the Lancet Clinic, July 22, 1905. He says:

Of all the products now in use as preliminary anesthetics, or as anesthetics for operations requiring but a short time, ethyl chloride or kelene is the most widely used. This product is obtained by the action of hydrochloric acid upon alcohol. It is a gas at ordinary temperature and pressure. As seen upon the market it is compressed into a colorless liquid; it is highly volatile and inflammable. Of its many varied uses as a local anesthetic we have neither time nor space to talk. As a preliminary anesthetic ethyl chloride is a splendid preparation.

Some three or four years ago, while riding on a train I chanced to pick up a Cincinnati Enquirer, and there in bold headlines was announced the fact that the surgeons of the Cincinnati Hospital had made a great discovery, and were using ethyl chloride as a general anesthetic. This was rather amusing. He reports that ethyl chloride has been used as a general anesthetic at Grant Hospital for about five years.

His method of administering this product is as follows: We place an ordinary Esmarch mask over the face, and spray the chloride onto it. If the operation is to be only a short one, continuous application in this way for one minute will produce anesthesia profound enough to keep the patient insensible to pain for at least three to five minutes. On awakening there is no nausea or giddiness. The confusion passes away in a few minutes, and the patient is able to converse in a natural manner. If, however, a major operation is contemplated, the ethyl chloride is applied in the same way for about thirty seconds, and then ether or chloroform is administered, giving it drop by drop, and increasing the amount gradually until profound narcosis takes place. The pulse

is stimulated, the face flushed, and the respiration even and regular when ethyl chloride is given. The great advantage of this procedure is that the stage of excitement is entirely eliminated, and much less ether or chloroform is needed; hence, the aftereffects of the anesthetic are lessened greatly. Nausea and severe vomiting are seldom seen after an anesthetic is administered in this manner. There seems to be no contra-indications to the use of ethyl chloride as a general anesthetic. It is safe in young and old. I have administered it many times, and seen it used hundreds of times without a single untoward symptom. But ethyl chloride is highly volatile, and hence expensive, as large quantities must be used owing to its volatility. The market price is high; the cost of its use for several minutes is from fifty cents to a dollar. In hospital practice this is quite an item. For the last two years we have used ethyl bromide as a preliminary and momentary anesthetic. This preparation is, I believe, the best of all when administered by one who knows its properties.

Ethyl bromide, or hydrobromic ether, is a colorless, inflammable, volatile liquid. It has a burning taste and a chloroform odor. This preparation, like the chloride of ethyl, has many uses, but we are concerned only with its use in anesthesia.

While interne at Atlantic City Hospital in 1900 we administered ethyl bromide about one hundred times. The methods employed for its administration were as follows: If the patient is a large man, or very nervous patient, or one of those big muscular hod-carriers that we see so often in the hospital, he recommends the quick method. This consists of dashing about one fluid dram of the drug upon a thick piece of gauze, and applying the same closely over the face. The patient is simply smothered in it. There are one or two struggles, and all is over. If the patient is very ill, not so nervous, or not so strong as to be able to overcome the etherizer during the administration of the ethyl bromide, he uses the slow method. This consists in applying the Esmarch mask over the face,. and then gradually dropping about thirty or forty drops of ethyl bromide upon the mask. After two or three deep breaths a towel is placed over the mask, and in one half to one minute the patient is sleeping quietly, and the same procedure as before takes place with reference to the ether or chloroform. The odor is not unpleasant, and scarcely

any irritation of the air-passages is produced. If properly administered there is practicaly no stage of excitement. The face is flushed, the ears red, the eyes injected, and the pupils more or less dilated. The heart action is accelerated, and the pulse increases in force. The respiration is quickened, and in some patients becomes snoring; but irregularity or arrest of respiration has never occurred. It does not produce nausea or vomiting. In fact, we seldom have any vomiting to amount to anything since we have been using ethyl bromide as a preliminary anesthetic. The duration of insensibility is brief, the awakening prompt, and there is little confusion of the mind when used for brief narcosis. Any untoward symptoms during or following the use of ethyl bromide are due to one or more of the following causes: I. Inexperience of anesthetist. 2. An impure article. Let me impress upon you that only a pure article is safe. We use Squibb's only. It should be obtained in one-ounce vials and never allowed to stand around and decompose. 3. Some physicians have mistaken ethylene bromide for ethyl bromide. The former is very poisonous. 4. It should never be used about a gas light, as it is readily decomposed. 5. It should not be used in old men with sclerotic arteries without due caution.

Ethyl chloride and bromide are of inestimable value in labor cases, fractures, dislocations, minor injuries, examination of women, especially in virgins, and in examination over tender areas. It should be borne in mind that where complete relaxation of muscles is required it is necessary to add a few drops of chloroform.

The cost of ethyl bromide, bought as we buy it, is nineteen cents per ounce. The cost of ethyi chloride is eighty cents per tube. The amount of ethyl bromide used is about thirty to sixty minims, costing about one to two and one-half cents per application, while ethyl chloride costs about forty to sixty cents per application. Ethyl chloride leaves a garlic odor to the breath; ethyl bromide does not.

In conclusion he summarizes as follows: 1. For brief operations ethyl chloride and bromide are the best anesthetics. 2. For preliminary anesthesia, these products are not only convenient, but I would impress you with the fact that there is less danger when the exciting stage is eliminated by their use. Ethyl