sote; if the expectoration is viscid and small in quantity, potassium iodid is indicated. Codein is the best sedativ to aid in subduing harrassing and exhausting cough. Other valuable remedies are the oil of eucalyptus, oil of santal, oil of copaiba, oil of tar, oil of cubeb, etc. The change of climate should be urged, but if he will not do it, you can do much by proper clothing, avoidance of exposure, and attention to ventilation and keeping the air moist and impregnated with the drugs indicated.-ED.]

Displaced Uterus.

Editor MEDICAL WORLD:-Patient, aged 39 years, mother of eight children, youngest two years old; family history good. Health good till last January, when she fell from barn loft, which produced an anteflexion of uterus, with considerable pelvic inflammation. An abscess formed in broad ligaments. Aspirated abscess in April, thru vagina. Patient improved for a month or more, then a profuse menorrhagia began at the regular menstrual period, which has continued to come on each twenty to twenty-four days, lasting from four to eight days, which has caused patient to become very anemic. Appetite, digestion, and assimilation very good, bowels kept open with lapactic pill at night. There was considerable enlargement of uterus, and a general corporeal endo-metritis, which still exist, tho uterus is now but little larger than normal. There is now but little cervical inflammation, nor has there been.

Treatment: After aspirating abscess, replaced uterus to normal position, and used cotton tampons daily to retain it, as patient could not bear pessaries. Used copious hot water vaginal douches, which have been kept up. Cotton soakt in borated glycerin. Cureted uterus, but no abnormal growths. Applied tr. iodin, sub-nitrate silver, and fl. ext. hydrastis to uterus internally. Have used different kinds of uterin supporters, and quite a lot of pessaries, both hard and soft, but owing to soreness, she can wear them only a few days at a time. Have not used one now in

the last sixty days. For past eighty days have kept her in bed, on the back as much as possible; put up uterus two to three times a week; it is easily replaced, but just as easy to "flop back" when patient laughs, coughs, or sneezes.

Medical treatment: Have used aletris cordial (Rio Chem. Co.), hypophosfites, iron, strychnin and ergotin, fl. ext. black haw, nuclein, proto-nuclein, pepto-mangan, and a few other tonics. For menorrhagia have used ergotin, fl. ext. ergot, tannic acid, alum, hydrastin, oil erigeran, arom. sulfuric acid, fl. ext. mistletoe, etc.; yet the menorrhagia continues to come. Now, brethren, help me to relieve this woman. J. P. PHILLIPS, M.D.

Yantley, Ala.

[You need to curet again, and more deeply. Try solution of adrenalin chlorid next time the hemorrhage recurs; give 15 to 20 minim dose, and repeat in an hour, if necessary. You can check the hemorrhage by tampons, and thus prevent too great loss of blood, but upon more thoro cureting will the cure depend. The internal and topical use of gelatin, as recommended in this column some months since, should also check the hemorrhage at any given period, but it will recur at the next, unless you remove the cause.-ED.]

Insist upon plenty of fresh air, without drafts, for every case of coryza, bronchitis, and pneumonia.

[There is no satisfactory treatment other than tonsillotomy, tho some cases are benefited by prolonged treatment. The enlargement and the chronic pharyngeal catarrh are interdependent, one on the other. Place the child in the best hygienic surroundings; insure fresh air at all times, but without exposure to drafts. Keep the stomachic and intestinal functions up to par. Apply counter irritation over the outside of the throat in the form of tincture of iodin, and later potassium iodid ointment containing a dram of ichthyol to the ounce. Give alterativs and tonics internally.

Have you tried hot air on your cases of obstinate lumbago? In many cases it gives considerable relief. Occasionally the constant wearing of belladonna plasters of generous size on the affected area will relieve. Diuretics are always indicated, and will often cure, in time, when anti-rheumatic treatment without including them is futil. We have often relieved lumbago by the old-fashioned "ironing" process Cover the affected part with a few thicknesses of damp flannel, and take a hot polishing iron and iron just as the laundress works on a shirt. The heat drives the steam against the skin, and it is astonishing what

markt relief is sometimes obtained. The water used to moisten the flannel can be impregnated with turpentine.

The morning vomiting of gastric catarrh is best treated by half drop doses of Fowler's solution hourly thruout the day, or the same drug may suit certain cases better given in larger quantities, before meals. Fluid extract of golden seal, non-alcoholic, is another valu able remedy for this class of troubles.-ED.]

Senile Gangrene.-Incipient Locomotor
Ataxia.

Editor MEDICAL WORLD-Case I. A lady patient age 65, came under my care a few days ago, suffering from dry gangrene of right foot involving at present the little toe and neighboring two toes together with a great portion of both dorsum and plantar surface of foot. The gangrene commenced in outer part of little toe, and involving it, extended to both dorsum and plantar surfaces of foot. It commenced about one month ago, and only this past few days has it extended to the fourth and third toes. However it is spreading, and I thought best to seek immediate help from headquarters, as I am puzzled as to which is best to do: await for line of demarcation, or amputate below or above knee. I have read up on it from Gould & Pyle's Encyclopedia, Walsham and Ericksen's Surgery, but before being satisfied write you for help. Examination of urin shows it normal. Her evening temperature

runs as high as 101°, and pulse 112; morning temperature 100°. She has been treated by some New York physician or physicians, who advertise largely in newspapers, and they a month ago pronounced it all of a rheumatic origin, and assured her of a cure in one month; but instead it has developt as above described, so she called me this week to take charge. I am keeping her at rest in bed, with foot kept warm by cotton batting coverings and bottles of hot water, and using vitogen as a dusting powder (Harvey & Co., Mfg.), and internally strychnin, gentian, quassia and quinin for aids to appetite and heart, also whiskey for stimulation, etc., and regulating liver and bowels with the ordinary anti-constipation tablets. So will the Editor or any of the WORLD family who have had success in these cases kindly help me out? as this is my first case of gangrene.

Case II-A man 67 years of age, a bachelor, came to me last March, complaining of a peculiar feeling in center of back-lumbar region. He had difficulty in getting up, but could walk fairly well when up. No other pains in body. Patellar reflexes almost gone. I feared locomotor ataxia but was not positiv. Gave him two treatments a week for a couple of weeks with the static electric machine, using only the static breeze with slight sparks, as he was anxious for electricity; and also gave him tonics of iron, strychin and arsenic; also hypophosphites. In the main my treatment has merely been tonic. There is not the slightest history of venereal disease in younger days. In fact, according to him he never knew woman or self-abuse. He is of a rather odd or peculiar nature. At present he suffers no pain, never has; his back improved and he says is all right; has gained in weight, and health is good, only he has to get hold of something to get up off a chair when sitting, or he falls back; also has to have hold of chair to sit down or he falls down on chair instead of sitting down on it as other people. Оссаsionally when eating he may take a slight choking spell, as from bolting of food or difficulty in swallowing. Other than this he claims he is all right. I cannot satisfy myself as to there being the Argyll-Robertson pupil,

and Romberg's sign is absent, as far as I can make out at present. Has full control of bladder and bowels, and on examining urin on different occasions found nothing abnormal. His intellect is clear and he is perfectly able to transact his business, only this condition or control of himself in sitting down and getting up off a chair compels him to stay home. Occasionally when walking he takes a tumble as he is not so sure footed as he used to be. He has not the peculiar walk yet of a patient with locomotor ataxia, such as I used to see in my college days at the hospital, probably because not so far advanced, if it is such disease. So now from what I have here described of his case, what is your diagnosis and treatment.

[Copy of private replies to queries of Dr. John Shultes, of Heathcote, Ontario, Canada, original replies having been immediately sent him (the consultation fees having been inclosed). They are here reproduced, as they are likely to interest and help others of the **: "family."]

CASE I.-Amputate at once, and well up in the thigh. The pulse and temperature are your valid warrant for such procedure. Your local treatment is all that could be desired, but early operation is imperativ if you wish to avoid re-amputation and probable ultimate failure. Your internal medication is correct; we merely suggest the addition of concentrated or predigested foods to the regular dietary.

Success in treating senile gangrene depends upon the recognition of the causativ factorocclusion of the arteries of the leg. Therefore the amputation must be thru the thigh. Failure will follow the method of moist poulticing and amputation close to the line of dead

tissue. It is necessary to get far enuf away from the dead tissue to make sure that the vessels at the site of amputation are in a healthy condition and that the tissues are not infected by organisms. By early amputation, high enuf up, you may anticipate healing without complication. We consider that your patient stands a very good chance if the above suggestions are followed.

CASE II. We think your diagnosis correct. We believe the patient should be kept on electrical treatment, even if he at this time feels that he does not need it. Not only may the advance of the disease be checkt, but there may be a certain degree of restoration of function. Snow advises the following method in similar cases: "Place over the region affected a soft metal (22 gauge) electrode two inches wide, and secure it firmly by placing a pillow against the patient's back; connect it with the positiv pole of the static machine, and administer the wave current, employing a spark-gap of four to six inches in length for at least fifteen minutes. Follow this with the same administration of short sparks to the soles of the feet after the following plan. Place upon a metal plate in front of the patient a piece of felt or several thicknesses of woolen cloth upon which the patient, having removed his shoes, should place his feet. Place the shepherd's crook from the metal plate to the positiv side of the machine. The spark-gap having been closed, separate it again gradually until it begins to produce a sensation disagreeable to the patient. Continue this administration ten minutes. This procedure assists materially in relieving the anesthesia in the soles of the feet. Follow this application with a general administration of friction sparks to all anesthetic areas on the body of the patient. Make these applications rapidly over the surface until the effect, at first mild, becomes disagreeable to the patient. [The fact that during a long course of treatment these areas do become more sensitiv is to the writer inevitable proof that the corresponding centers in the cord have been releast or have become more activ.] Long sparks, liberally applied over the region of the cord are indicated in all cases, for insuring relief to the congested conditions of the cord."

Once Argyll-Robertson pupil is plainly evident, it is never benefited by any treatment. Treat patient before this becomes too plain. The abolisht reflexes are rarely, if ever, restored.

You can do much for this patient by thoro and intelligently applied electro-therapeutics now; it is questionable what you can do later. Nothing beyond electricity and tonics and good hygiene will aid him in any way.—ED.]

Editor MEDICAL WORLD :-A woman age 30, while pregnant ten years ago had a pulse of 120 and still apparently in the best of health. Since that time it has been very irregular up to the present time. No pulse in the left arm can be detected and has not been for over a year; the pulse in axilla can be detected with difficulty. About four years ago she had a very severe dull, sickening pain in the lumbar region which was diagnosed and treated by some physician as neuralgia, and others as shortening of the uterin ligaments, but unsuccessfully treated. Finally coming into my hands, I gave her a full dose of morphin for the pain and large doses of salol, which gave permanent relief. My diagnosis was lumbago. About nine months ago she had an attack of psoriasis over face, neck and upper part of chest, and a severe vaginal pruritus lasting

about two weeks. Fowler's sol. of arsenic has been given occasionally, as necessary to control the psoriasis since that disease began. During the past year gradual paralysis has affected her left arm. More recently she feels a slight pain at times on top and left side of head. After exertion her left arm pains for a few minutes, and sometimes goes to sleep when resting quietly in bed. I have given nitrate of strychnin and the induced current to the arm with slight benefit. After walking she feels a girdle sensation around lower half of chest. The last few days she fears the right side is also affected. History good. Urin normal. During last three years has gained twenty-five pounds in weight. I find no sensitiv points nor pain on pressure, nor atrophy of muscles in the left arm. Her heart and lungs are normal except cardiac irregularity. May I ask for help from the Editor? Is it an obscure neuritis caused by arsenic? if so, why is pulsation absent in left radial? If arsenic cannot be given, what is best for the psoriasis?

Roseau, Minn.

FRANS. L. NORIN, M. D.

[We do not think you have arsenical neuritis in her case. You could not get a neuritis from arsenic without having had the symptoms which indicate the physiological limit, such as puffiness of under lids and pain in stomach. We would suggest putting her on codliver oil and thyroids. An ointment of salicylic acid, 20 to 40 grains to the ounce, is sometimes of great service. Alkalin baths are beneficial. Cut all meat out of her diet. ointment of white precipitate, 20 to 6c grains to the ounce, is highly commended by some authorities.-ED.]

Enteritis.

An

Editor MEDICAL WORLD:-Inclosed find draft for $3 to pay my subscription for 1903 and for three years hence. I have been very negligent in paying, but I can't do without THE WORLD. I have a case I want to ask you about, and I don't know whether I will write it up so that you will understand it or not, because it is my wife, and I am very much alarmed about her. She is 30 years old; she has had a mucous discharge from the lower bowel since June, 1900, taking suddenly with a diarrhea, lasting about thirty days. After that she gained in strength some, and a great deal in flesh, but still had the discharge from the lower bowel, of a mucous character, a little blood streaked sometimes, and she was going about most of the time until May, 1901. She then got worse and was down about half of the time that summer and the following winter until April, 1902, and then she gained strength and got stouter until February, 1903; but she still had that mucous discharge, and in April, 1903, she commenced to run down, and the discharge got worse. She has gradually grown worse since that until Saturday, when she had to give up and go to bed. She is very weak and emaciated, and the discharge is worse and looks now like the lining of the intestin. Dr. Lamon and I have diagnosed it tuberculosis of the bowels. Her lungs hurt her some and

are dull in places. She has the hectic flush, temperature runs from 98%° to 100°, pulse irregular. Just before that mucus passes, the lower part of her bowels commence to gripe, and when she goes to stool, perhaps there will be nothing-only gas and a little mucus pass, and that relieves her for a short time. Ill. F. E. T.

[Your wife has an enteritis, of course; but it is by no means plain to us that it is tubercular. In fact, some things you say lead us to believe that it is simple chronic enteritis. We do not know that we can state the case better than by quoting from Hemmeter, Diseases of the Intestins, publisht by P. Blakiston's Son & Co., as follows: "The differential diagnosis between simple catarrhal enteritis and tubercular enteritis hinges upon the presence of tubercle bacilli in the evacuations under conditions where the deglutition of bacilli can be excluded." You can easily make certain that no tuberculous meat or milk is being consumed by your wife, and it is easy to have some of the microscopical laboratories make the examination of the evacuations for the bacilli, if you do not have the facilities for doing this work yourself. We would do this, the first thing. We do not believe a case would have tuberculosis of the bowel for three and a half years, and present the periodical and substantial improvement she has manifested. The symptoms you describe are identical with many presented by simple chronic catarrhal enteritis. If the bacilli are found, the hopelessness of the case from a therapeutical standpoint will be apparent to you; if no bacilli are present, she should recover. suming that no bacilli are found, we suggest the following line of treatment: When the griping pain indicates that the mucus has collected in sufficient amount to be ready for expulsion, wash the lower bowel out with a simple warm water enema to bring away the mucus. Follow this by instillation of a pint of sweet oil containing five grains of iodoform and two drams of bismuth subnitrate; such an injection may be made every alternate day. It is made after the following manner: Have five feet of rubber tubing with an opening about the diameter of a lead pencil; fill a pint cup with the oil; fill the tube with the oil; have her lie down with the pelvis elevated on a pillow; insert one end of the tube into the bowel and drop the other into the cup of oil without allowing entrance of air; have her lie still until the entire pint of oil has entered the bowel; this may take fully an hour. If the oil stops flowing, it can be again started by gently withdrawing the tube a short distance, or by inserting it a little farther. We would keep her on tonics such as strychnin and codliver oil. We would give her full doses of non-alcoholic fluid extract of

As

golden seal; and of nitrate of silver, in pill form, so coated that it will be protected until it reaches the intestin. We would be glad to know the result of the bacteriological diag. nosis, and of subsequent treatment.-ED.]

Is it Poisoning by a Vine?

Editor MEDICAL WORLD:-Please prescribe for my son, who was poisoned by a bush or vine several months ago while cutting bushes, etc., in a meadow. I have failed to cure him, after trying everything I can find advised. The trouble first appeared on and above wrists, but it now appears on any part of his body, and comes and goes in a few hours. At times he seems well, but in a few hours, or in a day or two, the trouble returns. The swelling is very markt; the rash is very fine-more redness than rash. He will retire at night, some nights, apparently well, and rise next morning with a knot over the eye, or on the jaw, suggesting a bee-sting. I have run ashore on the matterdon't know what to do.

[See Editorial on Treatment of Dysmenorrhea in this (or next) issue. You can dilate and curet, and follow by wearing of the intra-uterin stem, if you so elect. Some cases seem to be bene fited by such treatment. No special technic is needed, and all text-books give complete enuf directions so that any doctor can do this work. The stem, if worn, must be removed occasionally for purposes of cleanliness, and ample exit should be provided for secretions. Any kind of tent can be used for purposes of dilation, if strict asepsis be observed, but the more scientific and rapid metal dilators are much to be preferred. The soft rubber stem pessary finds its most frequent use as a method of prevention of conception; the aluminum stem with provision for the escape of discharges is the best of the class. Whenever a stem pessary is seen without such outlet provided, it is certain that it has been intended to prevent ingress.-ED.]

Alkalies, such as sodium bicarbonate, or aromatic spirit of ammonia, with the addition of a few minims of chloroform, taken in hot water before rising, will often banish the intractable morning cough of chronics.

Reflexes in Myelitis.

Editor MEDICAL WORLD:-Would like to inquire if you or any of the fraternity know of any means that will control the jerking reflexes of the legs and abdomen in myelitis. I have a patient an M. D. (Bellevue), formerly of Indianapolis, but of late years practising at Phoenix, Ariz., who is afflicted with this disease; paralysis of lower limbs; no control over bowels or bladder. A cavity has formed at base of spine large enuf to insert a hen's egg. Was taken down a year ago last December (1902). Was in the Hospital at Los Angeles for several weeks; came here (a health resort) with the idea that I could help him, as I had relieved his wife two years ago of spinal and ovarian irritation from which she suffered a long time previous to her coming here. I am of opinion that recovery in his case is out of the question, tho he is very hopeful and insists upon it that he is going to get well. I called in a surgeon here who trims and dresses the sores on the back, but nothing we can do will control the reflexes. His age is 49. He is able to get outdoors in a wheel chair. He has been following a radical change of diet for many months, almost the "edemic" diet; appetite precarious. Is not his chance of recovery very remote? CALIFORNIA.

[Certainly it is very hard to glean any ground for encouragement from the data you give, excepting the fact that he is very hopeful, and insists that he is going to get well." Maybe he might; never allow yourself to give an absolutely hopeless prognosis. Summon all the psychic aid you can by agreeing with his wishes and hopes, and cheer him all you can by making him believe that you believe it.

We would try attending to the sore on the back without the aid of a surgeon. Wash it clean two or three times a day with bichlorid of mercury solution of sufficient strength to cause a slight smarting sensation (provided sensation is left at the site of lesion); we have used 1 to 1000 frequently. Then dust it well with oleostearate of zinc powder.

Arsenic and strychnin are indicated in many of these cases, and it is possible that you may be able to control the reflexes by the addition of gradually ascending doses of quinin. If the reflexes in this particular case are due to failure of the inhibitory nerves, quinin will do the work; it will do no harm to try it. Give it to the point of tolerance before abandoning it as a failure.-ED.]

A Recurrent Eruption.

Editor MEDICAL WORLD:-I come to you and the WORLD family for help in a case of my own, which is becoming very distressing indeed. Am 28 years old, and have always been perfectly healthy. When a boy I was poisoned regularly every summer with poison oak (rhus toxicodendron) until I reacht the age of 14 or 15. After that a similar "breaking out" would appear every spring without being poisoned by the vine, but only on my neck and back of hands. This condition continued several years, perhaps four or five, then became more frequent, but always the same eruption, until the last few years it appears about every two months, on an average. About one day preceding the attack, I have a gloomy feeling commonly called "blues," and on following day I can feel a small patch of bumps just back of each ear, and in a few hours it will appear all over neck, face, and backs of hands, but never below collar nor above cuffsalways on exposed surfaces. A stinging sensation

occasionally is about all the inconvenience it gives me. It first appears as an erythematous rash under the skin, and in a few hours comes to the surface in a hard nodular eruption, but never becomes sore. In every particular it is exactly the same as acute poisoning by poison oak, and will disappear in from three to five days under local applications of tincture iodin, one part, and alcohol, four or five parts. Any help from the Editor or readers of THE WORLD will be greatly appreciated. TAR HEEL.

[Your trouble, of course, has little or no relation to your having been poisoned by rhus toxicodendron. We often hear of such cases. The problem for you to settle is, What is the irritant that causes this periodical erythema?

We are inclined to believe that it is due to the uric acid diathesis or to a lithemic condition of the blood. Try the following treatment for the period of time covered by two or three attacks and intervening intervals, and see if you will not abolish the symptoms. Drink freely of water and avoid highly seasoned and rich foods. Take plenty of fruits, raw and cookt. Bathe the skin at least once weekly in hot water and good soap, and take a daily sponge bath with warm water followed by cool water and brisk friction in drying the body; five minutes is enuf for the daily ablution, but at least fifteen or twenty minutes are to be spent in the weekly bath; take time enuf to get all the dirt and oiliness well soakt out of the pores of the skin. Take enuf phosfate of soda every day to have a slightly aperient effect on the bowels. Also take two drams of solution of hypophosfites compound (without sugar) before each meal. If this does not cure you, add calcium sulfid, in grain doses, with each meal and at bed time, till the system is thoroly saturated with the drug. This should end your trouble. Alkalin diuretics may aid in rapidity of cure.-ED.]

Editor MEDICAL WORLD:-Can you publish the formula of Neurilla? It is manufactured by the Dad Chemical Co., of St. Louis, Mo. THE MEDICAL WORLD is the champion of the rights of the medical profession, and is an honor to the publisher. Harrisburg, Pa. W. O. SMITH. [Don't know the formula desired. Ask the Medical Brief.-Ed.]

Pain in Head and Dizziness.

Editor MEDICAL WORLD:-J. S., male, aet. 55. Some 12 or 15 months since began to have pain in head, confined to mastoid region and extending to temples. Has dizzy sensations; has fallen a few times. Six months since had sour stomach after midnight; has none now. Sexual appetite nil. Frowns; walking jars head and produces severe pain at points mentioned. Hesitates in speech; cannot relate a story consecutivly; no prickling sensations in hands or feet. Is melancholy; has fears for the future; is discouraged. Kidneys act well; no pain in micturition; urin normal; no jaundice; appetite good; bowels act well. Squints a good deal; is irritable; yawns frequently. Can not sleep well for the pain. Feels best when in the open air. Pulse rate 71 to 76; resp. 20; going up stairs produces shortness of breath,

Is well to do financially; has no debts nor domestic

[Your data are far from being complete enuf to enable one to make a diagnosis in a case which doubtless has complications. Your first best move is to decide what the character of the mastoid and temporal pain is. Do not until after you have excluded neuralgia, rheuconsider possible cerebral change or lesion matism, auto-intoxication, and eye-strain; if it is none of these, you may seek intracranial origin. We think if you had made a thoro enuf urinary examination, and had repeated it a sufficient number of times from specimens drawn at various hours of the day, and under varying conditions as regards sleep and meals, that you would have given us completer details regarding it. We doubt if you can be certain that you have no lithemic diathesis in the case; examin again carefully for the uric acid products. The vertigo and consequent falls may have occurred as a result of eye-strain or disordered digestion, and the former stomachic symptoms might indicate that, as one of the features of the case. It is always indicated in every case to get the digestion in the best possible condition and endeavor to maintain it there, even if no symptoms referable to the stomach are complained of; many a case of melancholia is cured by attention to the stomach and bowels. We can not now suggest diuretics, digestants, further than to place him for a time on alkalin together with tonics directed toward the mendiuretics, digestants, and saline cathartics, tal condition, such as strychnin, iron, and phosforus.-ED.]

Is it a Revisitation of a Form of Grip?

Editor MEDICAL WORLD:-There is a peculiar epidemic now raging in my vicinity. As yet I have been unable to make a diagnosis. It presents the following characteristics: The patient is seized suddenly with a severe chill, more severe than that of any other disease we have in this vicinity save pneumonia, and equally as severe as the initial chill of pneumonia. There are no prodromes. The chill occurs suddenly without any warning-sometimes waking the patient out of sleep; at other times coming on during daytime. He is seized with severe headache, generally frontal. The muscles generally ache. Simultaneously with the subsidence of the chill he experiences a severe pain in the side, generally the left side, in the region of the heart. In a small percent it occurs in the right side of chest below the right nipple. The pain is generally of a keen, cutting character, increased by breathing, Sometimes the pain radiates downward into the hypochondriac and sometimes into the epigastric regions. The temperature rapidly rises to 102° to 103° Fahr. In no case that I have so far seen has the temperature exceeded 103° Fahr. The patient immediately betakes himself to bed. There is generally nausea and vomiting, which is not very intense tho sometimes persistent. The pulse rises simultaneously with the temperature to from 100 to 120 in the adult. There is obstinate and