The treatment in this case began with gentle saline purgation for three days and absolutely liquid diet, most of which was sterilized. After this anesthesia, divulsion of sphincters, chemical cauterization of all ulcers in sight, insertion of a soft rectal tube, and thorough irrigation of the colon with two or three gallons of salt solution. I was not afraid of overdistension even in this case. When the water returned clear and practically odorless I then introduced about a gallon of formal solution, 3j to the pint. This was repeated three times at intervals of ten days, with marked benefit each time. The fourth treatment was given after a period of twenty days, and the fifth after a similar period. Sterilized liquid diet was continued until after the fourth treatment, when oysters, eggs, scraped beef and toast were allowed gradually. Recovery was apparently perfect. This case certainly looked like one in which colostomy was indicated. Further comment is un necessary. In my judgment it is absolutely essential to distend the folds of the gut to get at the disease within them. If this is not done, this or any other treatment has no value. Overdistension has never troubled me in these cases. I have on several occasions while giving this treatment caught myself fearing that I had allowed too much fluid to enter the bowel; but at about the same time the gut would contract, and the fluid would be expelled with a gush and with considerable force, carrying with it pus flakes and tissue shreds that could not have been gotten at in any other way. Distension of the gut is absolutely essential to the successful treatment of these cases, be they acute or chronic. The fluid should be allowed to enter until peristalsis occurs, when it will be promptly and forcibly ejected. There is nothing to restrain it. The sphincters are relaxed and a drainage tube is in the rectum. Only three precautions are necessary: The operator must keep his face at a respectful distance, wear rubber gloves, and be well protected with a large rubber apron. Physiologically speaking, it is a function of muscular tissue to contract; the muscular tissue of the bowel is no exception. It is true that this contraction in the larger is slower than in the small intestine, but it is there nevertheless. Once the limit of normal distensibility of the gut is reached, a wave of contraction is set up, which quickly and forcibly expels the dilating solution. With the gut in the condition of chronic or acute dysentery, the tonic and clonic contractions are more or less violent and continuous, as evidenced by the continual desire to defecate, and by the more or less tormina and tenesmus. In this chronic or acute state of irritability the gut will not hold as much fluid as under normal conditions, but that it will safely hold sufficient to distend it there is no doubt, some authorities to the contrary. Physiology also teaches that bacteria and bacterial decomposition favor peristalsis. This is consistent with what has already been said in the discussion of this subject, and certainly lends emphasis to my treatment of this disease, which, roughly speaking, is nothing more nor less than an acute or chronic specific decomposition within the large bowel, in the progress of which the bowel itself in whole or in part may become involved. The treatment as outlined lessens or arrests this pathological decomposition within the gut, favors the circulation, reduces swelling of the tissues, and soothes the general irritability of the intestine. The point may reasonably be raised that I have applied treatment promiscuously in a disease of varied etiology. To this I plead guilty. But until we get something more specific in the way of treatment, and until we have at our command a ready method of discrimination between amebic and bacillary dysentery, I shall continue to utilize the measures which have served me best, reserving for myself the privilege of being open to conviction, and this after using salines, calomel, ipecac and irrigation with various antiseptics, without the assistance of chloroform. That in my series of nineteen cases there have been several instances of amebic dysentery there is no doubt, as proven by the later occurrence of liver abscesses in two cases. That I have had several cases of bacillary dysentery I believe there can be no question, from the fact that seven of my cases were acute, some with sudden onset, high temperature, great prostration, and the passage of bloody stools practically odorless. It is said that bacillary dysentery is a self-limited disease, and does not often become chronic, but this does not controvert the fact that thorough colonic flushing removes myriads of bacilli dysenteria and all that this implies, lessens the severity of distressing symptoms, and reduces temperature. Experimentally and clinically it has been shown that bacillus Shiga quickly succumb under unfavorable conditions, and that they tend to adhere to the epithelial covering of the gut. The treatment I advocate meets these indications, in that antiseptic irrigation establishes an unfavorable medium for growth of the bacilli, to say nothing of the effect of the thorough hydrostatic scraping the epithelial lining of the gut receives by the large amount of fluid passing in and out. I have used various agents in this manner, including dilute alcohol in the shape of Pond's extract, hydrastis, permanganate, quinin, silver, and last but not least, formal. In the very chronic cases with much pus, a thorough flushing with formal is the first step after the preliminary injection of salt solution. This unquestionably lessened pus formation better than any other agent tried. The next treatment is usually silver, and may be followed with formal at the same sitting or subsequently. As already stated, I have never succeeded in finding amebæ in any case, notwithstanding I had skilled assistance. I feel convinced of having seen them, however, without recognizing them. I have therefore used quinin haphazard in two cases which tallied well with the description usually given of amebic dysentery, with very good results. Whether this was due simply to the thorough irrigation, to the quinin, or to both, I am not prepared to say. Suffice it to say that in a seemingly similar case permanganate apparently answered as well. In very acute cases silver solution, ten grains to the pint of fluid, acted best in my hands. the The argument will readily suggest itself that the same result may be obtained without anesthesia and without divulsion of the sphincter. To this I answer, it cannot. And my experience has been sufficient to enable me to speak positively on this point. In concluding I only want to state that I have brought this subject before you for what it is worth. You will not find it in any text-book that I know of. All I ask of you is to try the method first, and then pass judgment. In trying it, whether you fail or are successful, I would be pleased to learn the results, as in this way only can the efficacy or inefficacy of any plan of treatment for any disease be learned. My experience warrants the following conclusions : 1. The treatment of dysentery, acute or chronic, by topical application is most rational. 2. Topical applications are useless unless large volumes of fluid are used to distend the bowel. 3. Topical applications, as usually made, are very painful in all cases, particularly in those that are acute. 4. Topical applications, to be thorough and far-reaching, are unbearable to the patient, on account of the extreme pain they cause. 5. Anal divulsion is a prime factor in facilitating the work of flushing the colon. Resistance to the escape of fluid is removed, and it markedly relieves the tenesmus. 6. Anal divulsion, cauterization of ulcers through the protoscope, passage of a tube high up into the sigmoid through this instrument and thorough distension and flushing of the gut, are absolutely impossible without the aid of anesthesia. 7. Anesthesia rather relieved than produced shock in my These patients seem to take as kindly to chloroform as women in childbirth. cases. 8. In my judgment, one is more likely to overdistend and perforate the gut without anesthesia than with it. Randolph Building. CONSUMPTION IN GERMANY.-In no country in Europe has the fight against consumption been waged with so much persistence and success as in Germany. The following table shows the decline in the death statistics from consumption since 1876, the year in which accurate statistics were first compiled. The number of deaths refer to ten thousands of population: 1876 1901 Crefeld......... Breslau ......... Danzic........ Aachen Here are six representative cities scattered throughout the Empire, and the sta tistics show at a glance the immense progress which has been effected in twentyfive years.-The Leisure Hour-Med. Press & Cir., 1903. KIDNEY COMPLICATIONS IN ESTIVO-AUTUMNAL FEVER. BY IRA B. BARTLE, M.D. Surgeon Woods County Hospital. AUGUSTA, OKLA. ALTHOUн the subject is worn threadbare, and the material that I have to offer is of a very inferior type, the painful forcefulness with which the kidney complications have thrust themselves upon me in the last two years has caused me to groan in spirit many times, and even see some of my closest friends. slip from my grasp, when they were on a high road to recovery. So much has it been impressed upon my mind, that I never now treat a case, of even simple malaria, without at least an every other day examination of the urine; and I am satisfied that this precaution has saved to me the lives of at least a half dozen patients. The greater the number of crescents and flagellated parasites present in the blood (especially the latter), and the more free pigment, the more I deem necessary the daily microscopical examination of the urine; for with an excess of malarial infection, there is an excess of toxins (the excreta of fully developed parasites), producing inflammatory changes, or later, granular degenerative changes in the interstices of all glandular elements of the body, and especially the excreting organs. Among the excreting organs most notably affected are the kidneys and skin. When either of these begins to fail, the other is in a hard strait, and needs immediate attention; when the skin is acting beautifully there is but little cause for worry arising from the kidneys, unless the case tends toward the pernicious type; then all the corners must be thoroughly swept, and the cobwebs brushed down, for we may expect trouble from any source. The profound toxemia which follows a serious malarial infection may cause so numerous and varied a symptomatology, that the diagnosis is made with difficulty when one has to rely on the physical signs alone. Hence often autumnal fever is treated as typhoid or named typho-malaria, when it is truly a case of irregular fever, and is not amenable to typhoid |