changes in the liver and kidneys. As a result of this fatty degeneration of the nervous and liver cells, toxins are produced which are ordinarily eliminated, but which in certain cases are retained, and these toxins produce a definite chain of symptoms which appear in from 10 to 150 hours after the anesthesia, and consist in vomiting, retching, delirium, convulsions, coma, Cheyne-Stokes respiration, cyanosis, jaundice, and usually death. A certain number of mild cases are met with in which a transient jaundice occurs, and in which recovery takes place. Bevan and Favill consider that these hepatic changes are as definite as those found in acute pancreatitis, and that, as by-products in this toxemia, but not as the essential poisons, are found acetone, diacetic acid, and beta-oxybutyric acid in the blood and urine. They assert that the damage to the liver is so great as to cause a total destruction of this organ, and in their concluding remarks they state that this serious and evil late effect of chloroform, which has heretofore not been generally recognized, must still further limit the use of this powerful and dangerous agent. They believe that diabetes, sepsis, starvation, hemorrhage, and fatty degenerations contraindicate the use of chloroform, considering that the possibility of this condition arising also militates against the employment of chloroform in prolonged operations. In other words, they consider that a two-hour chloroform anesthesia in man is exceedingly dangerous.

We consider that this research of Bevan and Favill is of very great importance and requires careful study on the part of the profession. While their investigations are, to a large extent, in a new field, there can be no doubt that acetonuria, so-called, is capable of producing many of the symptoms recorded in the cases which they cite, and the so-called "cyclic vomiting" of children, who have not taken an anesthetic, is probably due to this cause. Edsall has recently published an interesting study along these lines in this country, and Muraille has done so in France.

In conclusion it may be interesting to cite the results obtained by Pringle, Maunsell, and Seton Pringle, which are published in the British Medical Journal of September 9, 1905, concerning the

effects of ether anesthesia upon renal activity. They find that ether distinctly diminishes the urinary flow, and decreases the elimination of solids, even more than it decreases the elimination of liquids. They believe that prolonged etherization must exercise an injurious effect in those cases in which these organs are already so impaired in their function that they have difficulty in maintaining their normal degree of elimination.— Therapeutic Gazette.

WHEN PERFORMING AMPUTATION, arthrectomy, osteotomy, or similar operation it is wiser to leave the constrictor in place until the dressing is partly, or entirely, applied, than to remove it after tying the large vessels, in an effort to secure the small ones. In the former case the snugly applied dressing will safely prevent hemorrhage; in the latter case, there may be an alarming loss of blood from the numerous small vessels in the very time the efforts are made to tie them all.- American Journal of Surgery.

ON THE USE OF NUX VOMICA IN HYPERCHLORHYDRIA.- In 1885 the writer presented to the Philadelphia County Medical Society (see Therapeutic Gazette, January, 1886) a communication on the use of ascending doses of nux vomica in various states. He pointed out that the value of nux vomica as a remedial agent was increased by the recognition that larger doses than usually prescribed could be borne, that a better effect could be produced by increasing the dose from a minimum dose to one which produces a physiological effect, and that such effect was more readily induced in old subjects, and that a tolerance of the drug was soon established, so that from time to time it had to be given in increased amounts in short, that the first dose should be fifteen drops t. i. d., and that every three days five drops should be added until a physiological effect is produced, as headache, slight "swimming in the head" or vertigo, or perhaps muscular rigidity. When the patient is seen daily the drug can be pushed to the extent indicated. Practically it was found that thirty to fifty drops was the average amount an old subject—i. e., one after

fifty could take, and forty to eighty the dose the young adult could take. It must be borne in mind that the initial dose must be small, and that ascending doses, to tolerance, bring about the best results.

It was further pointed out that the drug was most useful in asthenic and atonic cases, whatsoever the nature of the ailment. The underfed subject who was under weight and suffered from the great group of fatigue symptoms, local and general, singly or combined, was likely to be relieved by this remedy administered in the manner suggested. An example of the local effect of the remedy is seen in cases of eye-strain due to muscular insufficiency, as pointed out recently by de Schweinitz in his usual graphic manner. Whenever there is found a local disorder in the cardiovascular system, the gastrointestinal tract, or other portion of the economy, similar to the asthenic state of the eye muscle, nux vomica can be relied upon.

It is to a local disorder, and one the relief of which at first sight may seem paradoxical, we wish to call attention-i. e., the use of nux vomica in ascending doses in hyperchlorhydria or hyperacidity. It is well known that bitters are contraindicated in this state; that sedation rather than stimulation is required. In many instances we have found that sedative measures did not relieve the symptoms. A close study of the groups showed that they belonged to the class that had for its foundation a pure neurosis. In short, the hyperchlorhydria was not the result of a local irritative lesion, but an expression of a gastric neurosis the persistence of which was due to a general atony, or anemia, or a general fatigue neurosis. It is obvious that tonic measures would be required. To this class belong the hyperchlorhydria subjects in whom there is no cause for gastritis and no pronounced evidence of ulcer or gastritis. They bear all the stigmata of an exhaustion neurosis. They are usually thin and wan subjects. They may be hypochondriacal, and are often melancholic. They may have suffered from uterine or ovarian disease, show signs of gastroenteroptosis, or have evidence of chronic cholecystitis, with or without calculi, or of chronic appendicitis, or some other

infection. They are usually constipated. The heart is weak, the pulse small and feeble, and the tension low. The urine is at times abundant, watery, and hence of low specific gravity. but generally is scanty and high colored, of high specific gravity, and contains a faint trace of albumin and a few casts.

The class of cases outlined usually respond to ascending doses of nux vomica, and the symptoms of hyperacidity rapidly and often permanently disappear.-Prof. J. H. Musser, M. D., of Philadelphia, in Therapeutic Gazette.

FOR A SINGLE INTRAVENOUS INFUSION, as to combat the shock of hemorrhage, it is not essential that the solution contain any of the blood salts but the most abundant one sodium chloride. For repeated infusions, however, as sometimes used in treating various toxemias, it is better to employ also the other salts, the solution being made of sodium chloride 0.9, potassium chloride 0.03, calcium chloride 0.02, water 100.- American Journal of Surgery.

OBSTRUCTION OF THE PYLORUS.- Robert H. Halsey reports seven cases of pyloric obstruction, of which four were benign and three malignant. Six patients were operated on, five of the operations being gastroenterostomies. Of the operated three cases which were benign in character, only one was suitable for pyloroplasty. Only in one instance of the seven was permanent relief afforded by medical treatment. The author's conclusions are as follows: (1) A history of digestive disturbance extending over several years accompanies the non-malignant conditions; while a perfect euphoria, followed by a few months of increasing difficulty, is associated with the malignant cases. (2) A stomach distended with food contents and in active peristalsis, has an obstruction at the outlet, whether a tumor can be felt or not. (3) An obstruction of the pylorus may be due to a tumor which can be felt in another than the right upper quadrant. (4) The presence of lactic acid and the Oppler-Boas bacillus must not be interpreted to indicate the presence of a cancer; nor.

on the other hand, does the finding of free hydrochloric acid and sarcina contraindicate malignant disease. (5) Retention of food in the stomach can cause a suppression of the secretion of hydrochloric acid and permit the formation of lactic acid and the growth of Oppler-Boas bacilli. (6) The selection of treatment should depend upon the probable cause, as relief can be obtained in some cases without operation. In selecting the operation, pyloroplasty should have the preference when a choice is possible. -Medical Record, Jan. 13, 1906.

DO NOT EMPTY a thyro-glossal cyst by aspiration before extirpating it. It is well to inject the cavity with a methylene blue solution first, in order to make sure that all parts of the cyst wall will be extirpated. Another method is to first empty the cyst and then fill it with paraffin.— American Journal of Surgery.

THE SURGERY OF THE STOMACH.-Gastric surgery will be much more popular with the profession and the laity in the near future, according to W. D. Haggard, Nashville (Journal A. M. A., January 27), and early operation will be as universally advised for stomach lesions, as it is at present for appendicitis. Improved technic, low mortality and satisfactory end results, he says, will inevitably do away with the empirical treatment of occult intractable stomach diseases. The laity will also become educated and will criticize unnecessary delay in operating and allowing chronic ulcers to go on to perforation or fatal hemorrhage, or in allowing cancer to go unrecognized. Aside from malignancy, chronic ulcer and its complications furnish the majority of indications for operative interference in the majority of cases. Medical cures of these are apt to be overestimated, and do not compare as regards permanency with those from operation, while the danger to life is probably far greater. The various devices for gastrointestinal anastomosis are reviewed by Haggard and their respective advantages told, but he says that the ultimate ideal method has probably not yet been reached. The relative safety, even with varying technic, is illustrated by