that class of pleurisies which begin from exposure to cold or wet, which he classes as of rheumatic origin, and treats them considering the pleural cavity as a very large joint. In support of this treatment Le Fevre refers to observations which have been made in which salicylic acid was found in the pleura almost immediately after it had been administered, therefore he thinks it probable that it had a local curative effect. After the acute symptoms have disappeared, which is usually within two or three weeks, and the fluid is not subsiding, operative measures are to be considered for the removal. In cases of purulent effusion, removal at once by incision. between the ribs, or excision of a section of rib should be resorted to. Likewise there should be no delay in aspirating a very large serous effusion where intrathoracic pressure is evident, or there is dyspnea, for fear of heart failure. It is interesting to note the difference among leading teachers as to the time to aspirate. Dr. Page says, "Unless the symptoms be urgent, never operate during the acute stage. There is a great tendency to the formation of adhesions in pleurisy under the best conditions. To draw off this fluid during the active stage of inflammation, as evidenced in part by pain. and temperature, would simply bring the inflamed surfaces together that had hithertofore been kept apart by the effusion. Increased irritation with a more severe grade of inflammation would follow, and extending into the subserous connective tissue, would convert a superficial into an interstitial exudation, and result in a thickened pleura, if not extensive plastic adhesions." We find Quimby supporting Page. On the other hand no less a man than Delafield says he has " given less and less drugs until he has reached the conclusion that aspiration is the treatment for pleurisy, and is not to be employed to draw off the fluid but to cure the disease in the shortest possible time, it matters not whether the case is acute or subacute, or whether or not the patient is uncomfortable." He adds that "ordinarily only one aspiration is necessary, and the patient is able to be about within a week. Under the old treatment it usually takes three or four weeks, sometimes months." Drs. J. S. Winters, Beverly Robinson and W. H. Katzenbach claim a similar experience.

The withdrawal of a small quantity often starts absorption, and the whole then rapidly disappears. McPhedran says, "This is probably due to the removal of excessive pressure from the pleural vessels, allowing of their dilatation and of a free flow of lymph."

The point of aspiration is in the midaxillary line on a line with or a little below the nipple, as here the chest wall is thin and the spaces wide; this is about the sixth or seventh interspace. Only sufficient suction to maintain the flow is to be used.

Much cough, pain in the chest or the appearance of blood are indications to stop the withdrawal. Empyema is to be treated by free incision and drainage, care being taken to let the fluid escape slowly for fear of syncope. If there is doubt about drainage resect a rib. This is probably always best. The point of operation in both is at the most dependent point, to be determined by aspiration. It is rarely, even in infected cases, desirable to wash out the cavity with any fluid. Good drainage is usually sufficient, and if the fever does not soon drop it means usually that drainage is poor. In the treatment of all varieties of pleurisy it must be remembered that good food, fresh air, and a general supportive treatment are most imperative and should not be overlooked.

HEREDITARY DOUBLE UVULA.

BY RICHMOND MCKINNEY, M.D.

MEMPHIS.

Laryngologist to East End Dispensary and to Presbyterian Hospital.

It is not that bicornuate uvulas are particularly uncommon that I report this case, but it is the rather unusual transmission of this deformity to one of the patient's offspring that justifies calling attention to the occurrence.

The patient, a man 34 years of age, consulted me at the instance of one of our local physicians for relief from a persistent nasal stoppage, and during the course of the usual examination I noticed that he had a well-marked case of double uvula, the distinction between the two horns being so decided that each in itself would have constituted a fairsized normal uvula. On calling the patient's attention to this, he stated that the same condition was to be found in his son, aged 12 years. Examination of the boy revealed a duplicate deformity.

This is an apt illustration of the transmission of a deformity from a parent, and but bears out such occurrences as noticed in the lower animals, for instance the white spot on the forehead or the white stockings of a colt that he has inherited from his father.

Lyceum Building.

TYPHOID FEVER-DRUG ADDICTION-JOTTINGS.

BY W. S. ROBINSON, M.D.

FROSTVILLE, ARK.

TYPHOID fever is a disease in which the lesion is a congestion and ulceration of certain portions of the intestinal tract; it is undoubtedly due to a microorganism which obtains entrance into the body by way of the intestines. I think by far the most common mode of conveyance of typhoid fever is by the contamination of drinking water with excreta from a pre-existing case of the disease. Though water is much the most frequent source of transmission of typhoid fever, it must be borne in mind that milk not seldom plays the same rôle. But let that be as it may, the thing is to conduct the case through successfully. The first thing I do is to have the patient put in the hands of a careful nurse to whom specific directions must be given, if necessary in writing. As to its management, I myself at first superintend disinfection of discharges and giving of baths, administration of nourishment and the like. The sick room should be large, divested of all unnecessary trappings and capable of being always well ventilated. The bed must not be too wide, and should be so placed that it may be approached from both sides by the attendants; when prac

ticable it is often desirable to have a second bed in an adjacent room to which the patient may be carried for the night. This is especially gratifying to the patient when there is a tendency to insomnia or restlessness.

Complete rest in bed is imperative from the first day that the disease is suspected. There is no doubt that those cases do the best in every way and have fewer complications with best chances for recovery that have absolute rest with careful nursing from the earliest period of the disease. The mattress of the sick bed should always be protected by a rubber sheet placed immediately over it. Bed and body linen should be changed daily, or immediately if noticeably soiled.

My treatment is as follows: I commence at once and give six or eight grains of calomel; this sweeps out of the alimentary canal all toxic material, such as undigested and fermenting food, ptomaines and leucomaines. Calomel is regarded as one of the best intestinal antiseptics. It acts as an antiseptic in its own form, and indirectly by stimulating a more active secretion from the liver and intestinal tract. Calomel properly given lowers the temperature and shortens the duration of the disease. I give it whenever indicated throughout the fever, in small doses, about an eighth of a grain. After my patient gets the effects of the calomel, and the fever continues to run high, I give acetanilid and salol every three or four hours. After a few days, if the fever does not run above 103°F, I leave off the acetanilid and continue the salol throughout the fever. I have my patient sponged with warm water every day and I take special pains to find out if the patient sleeps well, for there is nothing which more effectually saps a patient's strength than inability to sleep. In nervous diseases this symptom is especially to be dreaded. I have made it a rule to prescribe bismuth subnitrate in all cases if the bowels run off, even if diarrhea is slight. You will have no diarrhea to amount to much if you use salol throughout the fever, with bismuth occasionally. In a case of depression, clammy skin or feeble pulse, sponge the skin and give brandy toddy and a little dilute muriatic acid in buttermilk to procure better relish of food.

Now, in regard to feeding in typhoid fever, I think we should be very cautious and not give too much food; buttermilk is my main reliance; I give it throughout the disease with crushed ice. Typhoid fever is a disease of malnutrition and exhaustion of the vital forces. There is a diseased state of the intestinal glands making absorption difficult. All authorities agree in considering milk in some form the best food in typhoid fever, milk being beyond doubt in itself the most complete of all single foods and, judiciously administered, the most practicable of all that can be employed in typhoid fever. It is an error to depend on it alone in the dietetic management; much water is required by the patient and considerable of this may well be administered added to the milk used. The tendency is oftentimes to overfeed in typhoid fever. It can not be too strongly urged on the nurse that pure water be allowed the patient in abundant quantity from the start. Water should be given freely though not in too large quantities at a time. If I could have but a single remedy, I would choose as pure water as could be obtained for that remedy, and leave the result to vital force.

I do not believe in dosing and doping the patient every fifteen minutes every two or three hours is often enough to give medicine. When night comes I let the patient rest with as little medicine as possible. Nothing should be left to chance with a typhoid patient; the kind of food and the hour given should be written out and the family told that nothing else goes. When the glandular system begins to act and the tongue to clean, the mind emerges from its stuporous condition and evidences of appetite begin to manifest themselves, you can increase your food. The intervals of feeding should be about two to three hours, and a trifle longer intervals may be permitted through the night, should the patient's condition be good and his sleep sound.

After the subsidence of fever and the approach of convalescence, a more liberal diet is permissible. Not infrequently what has seemed but a slight indiscretion in diet has apparently been the means of precipitating recrudescence of the fever and often perforation, followed by collapse and death. Early indulgence of the appetite in cases in which typhoid