renders it of markt value in diseases of the respiratory organs. It is indicated specially by imperfect or enfeebled respiration, and a condition of general relaxation. Digitalin is the great heart tonic, strengthening the heart and slowing the pulse. It is specially indicated by a rapid heart-beat and a feeble pulse. Combined with aconitin or veratrin it forms an ideal remedy for asthenic fever, and guards against the ever present danger of heart failure in the later stages of pneumonia. The standard alkaloidal granules of strychnin contain 1-134 grain, and of digitalin 1-67 grain. They may be given. once in a half-hour or hour until effect in fevers, but should not be continued thus for a great length of time.

In sthenic cases, after the use of the single remedy in the first stage, it is well to combine aconitin, veratrin, and digitalin in the doses named. In asthenic cases or stages, a better combination is aconitin with strychnin and digitalin. After the crisis, when the fever has passed away, and there remains a condition of depression, with danger of heart failure, omit the aconite entirely, giving the strychnin and digitalin only. Remember, the dose is not a definit quantity in a given time, but always the minimum dose as required to produce the desired effect.

Given one more drug, and most of the cardiac symptoms and complications of pneumonia can be satisfactorily met. Glonoin, or nitroglycerin, is the emergency remedy, relaxing the tense arterioles and letting the blood go free when the heart is overburdened. Its uses are to some extent the same as those for which alcohol was formerly employed by almost all practicians. Compared with alcohol, however, it is quicker in its action, freer from dangers, and more satisfactory in its results. It is often given in doses of 1-100 grain, but in my judgment much better results can be secured by the use of the 1-250 grain dose, repeated in ten or fifteen minutes if necessary, or even in five, if the case is urgent. It is not a remedy for continued use, or for permanent effect, but is strictly an emergency remedy. As such it is invaluable. It is best given in aqueous solution, and acts almost instantly. Or the granule may be chewed up by the patient, if he is able to do so. This is said to be the one drug which acts as quickly when taken into the mouth as when administered hypodermically.

With these five remedies well in hand, the doctor needs little more in the treatment of the febril symptoms in pneumonia. He will then be able to join with Dr. Burr in his closing statement, that "all the therapeutic nihilists to the contrary, therapeutics and internal medicin are, in the opinion of most of us, becoming more accurate, scientific, and exact every day, and it is much more of a pleasure to practise medicin in these

degenerate (?) days than in the days of our fathers. J. M. FRENCH, M.D.

Milford, Mass.

Treatment of "Nose-bleed."

Editor MEDICAL WORLD:-I am tempted to "rush into print" by a recent description of nasal plugging in your journal. Possibly a few ideas along that line may be helpful to somebody. Nasal hemorrhage almost always is from a point just within the nares, on the septum; because in this spot there is a particularly rich capillary zone, and the membrane is very thin and easily abraded. Practically all spontaneous hemorrhage starts here. People who are prone to nose-bleed, and who have it repeatedly and without any apparent cause, will show an ulceration at this point. Examination will show, as a rule, a little scab; and only a very slight manipulation is necessary to cause bleeding. If two scabs are seen, one on each side of the septum, directly opposit each other, there is almost surely a perforation. It is surprisingly easy to get a perforation from "picking" the nose, when once an ulcerated zone is establisht. There is a hemorrhage; the blood dries into a crust; the patient "picks" at the crust, and then the cycle is repeated. These hemorrhages are very troublesome to the patient, and I have seen many cases where they were of sufficient frequency to actually cause an appreciable anemia. They are easily stopt. Cocainize, by placing a cotton tampon against the ulceration and let it stay there 10 minutes. Then touch lightly with chromic acid fused onto a probe over the ulcerated area, and a little beyond. Wipe dry very gently, and direct the patient to let it alone, and to keep on letting it alone. I have cured many cases by one to four such treatments-generally by one or two.

If there is perforation, clean it out, get the edge free from all crusts, and treat the same way. A perforation is ordinarily of little consequence. Many people have one and don't even know it. For hemorrhage, use ordinary cotton laid over the bleeding point. This gives the blood "something to stand on," and usually produces prompt clotting. Pack with moderate firmness. If this is insufficient, a Bernay sponge is the finest possible packing, and all physicians should have a few in their kits. Saturated solution of tannic acid is excellent and not unpleasant. It is a powerful styptic, and one which I always have at tonsil operations. Dioxygen is also fine. Inject freely with syringe, or put the patient's head well back and pour it in with a spoon. I once put some into a squirming youngster by sucking it up into a straw and then injecting into his nose.

In case the nose must be plugged posteriorly, which is rarely demanded, the easier way is by means of a soft catheter; but not as per the recent description in your paper. That

was not easy. Wet or oil the catheter, and, holding it near the point, insert it into the nostril as low as possible-aim it considerably downward-more so than would seem natural. Make it follow the nasal floor. This is vitally important for easy introduction. When the catheter has passed into the pharynx, catch it there with forceps or fingers and draw it 'out of the mouth. You now have one end projecting from the mouth, and the other from the nose. Now tie your plug by at least a foot of strong cord (doubled) to the mouth end of the catheter, and draw it into the mouth and up behind the soft palate. The palate often resists its passage. If so, tell the patient to close the mouth and then "sniff” as tho smelling. This will relax the palate for a second or two, and you can get the plug packt in. This method will usually succeed, even in the hands of men inexperienced in nasal technic. It may fail on account of deviated septum, spurs, or large turbinates; but the catheter will worm its way thru, where a stiff instrument cannot go-and it can do no harm. Of course, if I had a nasal hemorrhage in my office, and the patient was manageable, the technic would be direct pressure over the bleeding point under illumination. But anywhere else, or with an unruly patient, the above method is the best, and will apply to almost every case. Newark, N. J.

E. H. BALDWIN.

The Efficiency of Hydrogen Peroxid in Lavage.

Editor MEDICAL WORLD:-In the treatment of gastric disorders in which lavage is used to cleanse the walls of the stomach, I have failed to find any mention whatever in medical literature dealing with peroxid of hydrogen for this purpose. The action of peroxid of hydrogen upon mucus secretion intermingled with epithelial cells and inflammatory detritus causes a white, lathery foam; and especially so if it contains any pus cells. Take a case of chronic catarrhal gastritis where the mucous membrane of the stomach is covered with a thick, tenacious mucus, the usual methods of lavage in which alkalin solutions are used we cannot free the walls of the stomach of its viscid secretion. When peroxid of hydrogen is put in the stomach it causes a breaking up of the cells upon the surface of the membrane, forming air bubbles and producing a buoyancy of the mass of mucus. This can be observed during lavage by catching some of the washings in a transparent vessel.

The following method I have used for the past three years in the treatment of chronic gastric catarrh, and also gastric ulcer: One hour before meals, when the stomach is practically empty, four drams of aqua hydrogenii dioxid (U. S. P.) diluted in eight ounces of pure water is given the patient. Following this about fifteen minutes the stomach tube

is introduced, and a thick, grayish-white foam is drawn off, and therewith a considerable quantity of mucus. To facilitate this, sterilized water may be introduced into the stomach. After a thoro washing with plain water another solution of peroxid of hydrogen is introduced. After waiting for a few minutes for this to act it is drawn off, and the stomach is again washt out with a plain sterilized solution. The two solutions are usually sufficient for one sitting. The action of this method of cleansing upon a gastric ulcer is obvious from analogy—a clean surface.

Between washings and while the patient is at home the patient is instructed, providing he has not been taught the use of the tube, to take two drams of peroxid of hydrogen well diluted half hour before meals. An eructation of gas and sometimes froth will follow the ingestion of peroxid of hydrogen.

A report of but one case: A minister, age 42, was compelled to give up his charge in the East on account of poor health. He attributed his sickness to heredity, his grandfather having died of alcoholism; saying that his teeth were on edge from his father eating sour grapes. Inquiry into the case revealed the fact that he was suffering from chronic catarrhal gastritis.

The first washing was given in the morning before he had taken his breakfast, as at this time he had no appetite and suffered from nausea and frequently vomiting. The above method was pursued. The great quantity of foamy mucus removed was surprising, giving the idea of a "gastric shampoo." After the stomach was thoroly cleansed, a solution of hydrochloric acid, tincture of nux vomica, and pepsin was introduced, and the tube withdrawn and he was soon ready for his breakfast.

The foul-smelling breath and nausea and vomiting stopt with this one treatment, and a healthy appetite returned.

The treatment as outlined was kept up for two months, lavage being practised weekly. Where a thoro cleansing of the stomach is desired, the method as described has proven more satisfactory than the usual methods set forth in text-books. G. H. GILMORE. Murray, Neb.

Postpartum Hemorrhage.-Simplified

Spelling.

Editor MEDICAL WORLD:-For twenty years THE WORLD has been numbered among my favorit journals, and it still holds its position. The Editor's strong words on "Postpartum Hemorrhage and Its Treatment" are timely. While not using ergot as a "routine measure," I give what I consider preferable -quinin and ipecac. The former will undoubtedly increase uterin contractions, and encapsuled with the latter serve as a prophylactic against hemorrhage. This combination also dilates the os uteri, leaving the body of the womb after the expulsion of the child

and placenta in a state of tonic contraction. I have never had a case of severe postpartum hemorrhage. If I were called on to treat a case, I should quickly resort to a remedy not mentioned in the Editor's excellent résumé of treatment: a hypodermic of morphin and atropin. Whenever a known "bleeder" is attended, the syringe should be charged in advance and made ready for an emergency. In less than a minute its contents can be thrown into the circulation, and No. 1 of the series instituted. Atropin sends the blood to the extremities, filling the arterioles and thus lessening the blood supply in the centers and so causing the hemorrhage to be more easily controlled. A call for vinegar may not be promptly responded to, but a lemon in the obstetric case can always be had quickly, and can be relied on as cleanly.

I do not suppose that Dr. Wetter is responsible for the caricature of the word "preventiv" (should he write in English), by the addition of the syllable "at." Nor do I suppose that Dr. Taylor, one of the champions of simplified spelling, is responsible for the addition either. But only by some lapsus has it made its appearance in THE WORLD. I would not have alluded to this matter if it had not been for the opportunity it gives me of again calling the Editor's attention to two words which in their simplified form ought to appear in THE WORLD'S standing list. They are symptomology, not symptomatology, and systemize, not systematize. Let the Editor do this, and THE WORLD will be the first periodical to call attention to these changes which etymology sanctions and brevity demands.

Lytle, Texas. JOHN FREEMAN NEAL. [We have long endeavored to knock the superfluous at out of preventativ, but sometimes it will creep in in spite of our efforts. We heartily sanction the omission of the superfluous at from symptomatology and systematize; symptomology and systemize are much preferable.-ED.]

A Case of Postpartum Hemorrhage. Editor MEDICAL WORLD:-Having read about several interesting cases of obstetrics in THE MEDICAL WORLD lately, I wish to report a case of postpartum hemorrhage, which, by the way, is the first severe case of that nature which I have met in my short time of practise, about two and one-half years. About five o'clock in the afternoon of September 4th, I was called to the home of a German farmer about six miles distant, where the woman, a thirty-year-old multipara, was said to be in labor. On arriving, I found that the pains had eased up just before I came. I cleaned the patient, disinfected my hands, and then made a vaginal examination, which showed that the os had not begun dilating at all; it was pointing backward toward the rectum. On my assurance

that it was perfectly safe for the woman to be on her feet, she got up and helpt prepare supper. I waited about two hours, but no pains occurred during that time, so I went home again.

Next morning about three o'clock I was again called. This time the pains were real enuf, but short and seemed to lack in force. Now the os had dilated one and a half inches. I gave the woman 6 grs. of quinin sulfate and waited. The pains increased somewhat for a couple of hours and then seemed to slack up again, when I gave her 3 grs. more of quinin without any appreciable effect. About 7 a. m. the os was completely dilated; the pains were still weak and short, but the bag of water broke naturally anyhow, and finally, about 9 a. m., the woman gave birth to a 10-lb. baby. I secured contraction by kneading the uterus thru the abdominal wall, and proceeded to clamp and cut the cord. While doing this I noticed profuse hemorrhage, wherefore I again rubbed the uterus to check it. The uterus responded, but I kept on kneading it gently to prevent any more bleeding.

In spite of my efforts the uterus relaxt and soon again considerable hemorrhage occurred. Then I thought I would better deliver the placenta, which was easily done by Crede's inethod, but now the hemorrhage was simply alarming. Massage would make the uterus contract for about a minute, then it would relax and about a teacupful of blood was lost each time. There was no help at hand except an elderly woman of questionable cleanliness and another woman who knew nothing about asepsis. I realized that I was up against it. In an instant I thought over the means of checking postpartum hemorrhage which our professor took so much pains to make us remember while at school, but they seemed to be out of reach, excepting ergot, massage, and packing.

Well, I did not hesitate much, but gave one dram of ergot and resorted at once to packing, using a steril gauze bandage introduced loop by loop while I held down the fundus with my left hand. This stopt the hemorrhage.

But now the woman was very weak, radial pulse almost imperceptible; the face was pale and pinched. I elevated the foot end of the bed about eighteen inches, and gave a pint of warm saline solution by rectum. This seemed to brace up the woman in a little while, so that we all began to feel easier. I left the foot end of the bed elevated. After cleaning up around the patient and finishing up the case as usual, seeing that the baby was properly cleaned and drest, I left the patient in a fairly good condition under the circumstances.

The packing was removed next day and no fever followed. The patient made a slow but uneventful recovery. However, it was

four weeks before she was able to be up in spite of tonics and good care, and then for a while her ankles would swell when in the upright position. At the present writing she is again doing her own housework.

Can any of the WORLD family tell me if my giving the quinin to stimulate the uterus to contract more forcibly had anything to do with causing the hemorrhage?

Dannebrog, Nebr. P. M. PEDERSON.

Treatment of Eclampsia.

Editor MEDICAL WORLD:-If any apology is needed for writing what is already known by most of the WORLD family, I will say, as it is made up mostly of general practicians of medicin, and this paper may serve to freshen the subject in their minds. I will ask you to follow me while I try to discuss the treatment of this dreaded disease, held in fear by so many country doctors.

Even at this advanced day in medicin, it is customary in most sections of the country, and by a great majority of our best people, to see a physician from one week to several months before the expected date of confinement; and it is considered by a great many of the doctors in the country and small towns that their attention to a pregnant woman commences when she enters into labor. The husbands of these pregnant women, or possibly the women themselves, call to see you and advise you of the expected date of confinement, so as to impress it on your mind, rather than to tell you of their condition and ask for advice as to mode of living, which would bring the patient to full term in better condition; and often the doctor consulted encourages the caller by dismissing him or her with the advice to send for him when needed. Possibly this is the last time he sees or hears of her until she is taken in labor. There is no excuse for this, and yet you find it true of a great many of our doctors; and so long as it is continued in this way, we will continue to have eclampsia.

I think we will all agree that the chief condition we will discuss is toxemia. Its nature and source are comparativly unknown; but with the toxic material in the tissues and blood, the treatment aims at the control or elimination of the poisons in the most rapid manner possible, at the same time being careful concerning the safety of the patient.

First in treatment is the prevention of toxemia of pregnancy. This is usually simple. It calls for fresh air in abundance, exercise not to excess, avoidance of constipation, daily bath, suspending the clothing from the shoulders to avoid pressure on abdomen, avoidance or chilling of body and limbs by wearing light flannel, a nutritious and easily digested diet with small proportion of nitrogenous matter, frequent examination of urin, noting the amount passed in twenty-four hours and testing carefully for

albumin, getting full history of patient and noting her physical condition. If all of this is properly done, serious cases of toxemia should be prevented.

If we neglect the above, or the patient fail to carry out our instructions, or occasionally in spite of our care we see conditions arising which we know to indicate toxemia, by finding albumin in the urin, decreast amount of urin, slight swelling of the extremities, some jaundice, nausea and vomiting coming on late, headache, disturbance of vision, pain in epigastric region, and mental excitement, we know we must get to work activly to remove the cause.

Now we come to the relief of toxemia. If mild in character, slight nausea and vomiting, little edema, small quantity of albumin, slight disturbance of vision and mild headache, it will be generally relieved by an activ purge, calomel and soda in broken doses, followed by salts and cream of tartar; cut out food except bread and milk, promote diuresis, bromids and chloral to quiet nervousness, and fresh air, avoidance of exercise to excess.

If when patient is first seen she has severe toxemia and we recognize symptoms of impending eclampsia, such as markt disturbance of vision, severe pain in epigastrium, severe and persistent headaches, markt diminution of urin with casts, extremities much swollen and boggy, and albumin accompanying jaundice, we must resort to activ treatment, viz.:

Put patient to bed and insist on complete rest; exclusiv milk diet; give calomel and jalap until activ purgation; follow with salts and cream of tartar, or cream of tartar lemonade; chloral and bromids to relieve nervousness; hot pack once or twice daily; nitroglycerin; hot normal solution by rectum to increase action of kidneys. Most important is free purgation, hot pack, and normal saline solution, exclusiv milk diet and rest in bed; most cases will improve under this treatment.

If

If, however, no improvement occurs, we will have to consider premature labor. Very often we find the os dilated so a finger can be introduced, and if such is the case we have no serious trouble to dilate with the fingers. this cannot be done, we can use Barnes' bags. They are sure to do the work, and do not cause much shock. The rubber catheter or bougies are too uncertain and slow. I do not think the metal dilators safe; they lacerate the cervix, and by far too much shock and danger of sepsis is incurred, tho occasionally they have to be resorted to. Williams, of Johns Hopkins, claims that Cesarian seetion is more conservativ than forcible dilation with steel dilators.

I will now take up the treatment of the convulsiv attack. We have only a few remedies that we can depend on: (1) Chloroform is the sheet anchor. Walking into a room in the midst of a convulsiv seiz

ure, I think you should chloroform your patient at once, and do it thoroly. You can then prepare yourself for further work. If pulse is extremely rapid and cord-like, and at the same time full, give 30 min. of Norwood's veratrum viride hypodermically, and if pulse does not slow down and improve in thirty minutes, give another hypodermic of veratrum, 15 minims, and continue to repeat every thirty minutes until pulse is down to 70 per minute. If you find collapse and gastric derangements from its use, counteract by alcohol. You will find that veratrum promotes diuresis and diaphoresis, and relaxes the cervix and reduces the temperature. I consider it safely the second drug in treatment of eclampsia. Third, morphin sulf. is much advocated by the profession in this dreaded disease, but I find while it helps to control the convulsions and quiet the nervousness, it dries up the secretions and the patient is unconscious much longer, and takes much longer time to rally from the attack. Therefore, I do not use it if I can avoid it. Fourth, chloral is one of the general favorits with most of the profession in this trouble. Give 20 to 30 grs. dissolved in hot water by rectum, or chloral 20 grs., bromid potass. 30 grs. by rectum.

Another method of controlling the convulsions is by emptying the uterus. You will generally find the os partly dilated after a convulsiv seizure, and you have no difficulty as a rule to deliver. If the os should not be dilated, be careful and do not rush matters; use Barnes' bag; take your time, to prevent shock and laceration. Now, while the convulsions are being controlled by chloroform and other medicinal measures and the uterus emptied, you must eliminate the poisons. Use your hot pack; nothing is ahead of it; it brings on a profuse sweat by which you can remove an enormous amount of poison. It also quiets the nervous system. Give at the same time hot normal sol. in the bowel. This sol. is rapidly taken up by the blood vessels. Don't forget venesection; bleed to the amount of 12 to 16 3. I have yet to see the time it did not do good, especially when used in conjunction with saline sol. and hot pack. Give 2 drops of Croton oil in a little sweet oil on back of tongue, or elaterium, togr., dissolved in a little warm water. If your patient is suffering with collapse use alcohol freely, nitroglycerin, and digitalis; nitroglycerin acts both as a heart stimulant and diuretic.

You can't be expected to use all of the above measures in every case, but if the case is seen early and treated intelligently, using your chloroform, veratrum, emptying uterus, thoro purgation, hot pack, and normal salt sol., you will find most of your cases recovering. I am offering this paper to impress upon the subscribers of THE WORLD the necessity

[It used to be thought that to prevent albuminuria was to remove danger of eclampsia; and, conversely, that the presence of albuminuria was a pretty safe indication that eclampsia would occur. While there is some truth in this theory, yet a number of cases of eclampsia have been observed without albuminuria, and many severe cases of albuminuria have been delivered without the occurrence of eclampsia. Thus we see that, while there is a link between albuminuria and eclampsia, yet there are other important factors. The whole truth cannot be better exprest than by the single word, toxemia. Under the kidney (albuminuria) theory, the toxic material was supposed to be urea, or chiefly urea. While urea may be a part of the toxic material, it is not the chief element -and what the chief element is we do not yet know. When we consider that the mother not only has to keep her own blood pure, but also that of her growing babe, and that the babe has no facility for excretion, either by kidney, bowel, or skin, except thru the mother's blood, we see a powerful and constantly acting cause for maternal toxemia. The treatment, both preventiv and curativ, as suggested by Dr. Vest, is the promotion of elimination by all the emunctories of the mother, pure air to promote oxidation, and restriction of diet to lessen the burden of elimination. As the liver is the chief depurator of the blood, its action should be watcht as carefully as that of the kidneys, if not more so. We see a large physiological problem here, not one confined to the kidneys alone-ED.]

Hydrocephalus Apparently by Maternal Impression.

DEAR DR. TAYLOR:-On Nov. 23d I was called to see Mrs. W. Messenger said they thought she was dying. I found her with feeble pains. Her previous labors were very rapid. I gave a dose of quinin; pains became stronger. Ruptured membrane; in about two hours another bag of water presented itself. That being unusual, I called in Dr. Dickerson. We opened the head and about one-half gallon of water passed, and child was born. It proved to be a hydrocephalic child, without eyes, ears, nose, thumbs, or anus. The entire brain was not larger than a small hen's egg. Now, Mrs. W. saw a hydrocephalic child during her first month of pregnancy. Says it bothered her. She could not get it off her mind. The child's face was exactly like the one she saw last March.

Mrs. C. was with the child every week from its birth till its death, Aug. 18th, and I delivered her of a fine boy, Nov. 19th, without a blemish. Mrs. C. said seeing the child did not bother her at all.