Constitutional.-Before any specific measures one must place food. Whatever view we may hold on the pathology of this condition, there is no doubt that malnutrition exists. Anemia is, as a rule, plainly marked, and therefore food must be abundant, varied, fresh and digestible. Fresh fruits and vegetables; a due proportion of starches; sweets limited, or quite excluded, as well as malted and most spirituous liquors (particularly beer and sweet wines), and meats being used rather freely. More particularly fats are a necessity, as shown by the value of codliver oil in such cases. Onions and celery are two vegetables of which such authorities as Whitla speak highly. Onions especially are valuable on account of the high proportion of sulphur which they contain. Extremes in diet are usually unsafe. Fads, such as the Salisbury treatment on the one hand, and vegetarianism on the other, are a mistake. As to medicines, they may be grouped into the two classes, of alkalies and alteratives on the one hand, and hematinics on the other. The first group contains all the iodides, specially sodium iodide, arsenic and sulphur, and, of course, the ordinary potash and soda salts. The danger in their use lies in forgetting that alteratives without good food and exercise are depressing and aggravate the anemia already present. The alkaline cachexia of patients who go without supervision to the various antirheumatic water-cure establishments is familiar to us all. The Iron Treatment.-As to this treatment, details cannot be given. Suffice it to say that the form which I have found most useful is the soft Blaud's mass with arsenic, made by Duncan and Flockhart. Salicylates are useful for pain, given in moderate quantities. Ziemssen says one dose at bedtime of 40 grains or so. Sulphur, both internally and externally, is sometimes of marked value: a heaping teaspoonful in honey or marmalade each morning and the powder freely dusted over the wool with which the inflamed joint is dressed. 3. COMPLICATIONS.-The surgical or orthopedic treatment of the results of chronic rheumatism has already been taken up by Dr. Nevitt. We now reach, finally, the third main subdivision of rheumatism-that of complications. The two main complications of acute rheumatism are carditis and hyperpyrexia. As to heart complications, no attempt can be made to discuss the topic through lack of time. It is one on which many a volume has been written. Hyperpyrexia.-This one may define as being a temperature of 105 degrees F., especially if it has been reached rapidly, with signs of going on up. One must then remember that the heatregulating mechanism is hopelessly upset, and therefore attempts to control the situation by drugs are probably useless. A priori, one would use antipyrin, antifebrin or phenacetin, as the increased temperature is due to increased heat production, not to diminished heat loss, and these drugs act by diminishing the heat production through their effect upon the oxidation processes in the body. The authorities agree that time spent on them is wasted, and that the cold pack or bath used at once gives the only means of escape. Besides being a waste of time these drugs are depressing to the heart, already sorely tried by poison and fever. Dr. Armstrong, of Buxton, has spoken strongly in favor of the immediate use of the cold bath, and believes that in many cases the time spent in cold sponges or baths has determined a fatal issue. His method and rules are that the patient should be immersed in water at 92 degrees F., which should be cooled down to 72 degrees F., and the patient kept in usually from ten to thirty minutes, with ice to the head, until the temperature falls below 100 degrees F. The condition of the heart calls for careful consideration during this procedure. On replacing the patient in bed, warm blankets and hot water bottles should be applied. The bath should be repeated as often as the temperature reaches 105 degrees F. I can only close my contribution to this symposium with congratulations to the other Fellows on the programme upon the character of the discussion, and with thanks for the pleasure they have given me as I listened. As for my own share in it, I can only express the hope that it may be half as serviceable. in systematizing our ideas on the subject to the rest of you as it has been to myself. SEPTICEMIA AND THE CURETTE. BY H. PLYMPTON, M.D To attempt to break up an old established custom in any line of life is at best a thankless job, and one likely to call down harsh criticism upon the head of the daring iconoclast. To attempt to uproot old prejudices existing in favor of a certain line of practice in surgery, and diametrically oppose such practice, is to invite from some adverse criticism of the harshest kind. The only recompense for this is a logical refutation of, or concurrence in, the argument advanced on the part of other members of the profession. This latter is what I hope for, and if I provoke a discussion or start a line of thought in the minds of half of the readers of this article, I shall have achieved all I started out to do. Curetting the uterus to remove fragments of afterbirth or other debris, has been taught in our medical schools from time immemorial, and it is firmly fixed in the receptive and retentive mind of every medical student that the first move following any such abnormal uterine condition is to cleanse the uterus by means of the curette. That the organ should be thoroughly and aseptically cleansed admits of no argument, but that the work should be done with the curette, I deny most emphatically. The majority of cases of death following the decomposition of fetus or placenta in utero are caused by the use of the curette, and I hold that septicemia may be avoided if a more rational procedure be resorted to. The condition of the uterus containing septic matter is one of great congestion, the thickened walls being coated internally and over the os with a thick, brown, tenacious mucus. The congestion is active, and therefore the more dangerous in the event of the admission of septic matter into the circulation. If the curette is used, denuding the walls of their protective covering, an immediate vaccination takes place with a septic virus, septicemia following in an incredibly short space of time (chemical metamorphosis is marvellously rapid in the circulatory system) and death quickly ensues. If, without using the curette, we can remove the septic matter from the uterus without disturbing the mucous covering, and enable the uterus of itself to expel the coating, we shall have taken a long step forward in the treatment of this class of uterine cases. The uterus, by reason of its congestion, may be made to perform a self-cleansing act by exciting the exudation of the serum of the blood into its cavity, thereby washing itself out, and expelling all septic matter instead of absorbing it. This process of exosmosis is induced by a properly combined alkaline solution at a temperature above 100 degrees, and a strict avoidance of bi-chloride, carbolic acid, formaldehyde, or any antiseptic of an acid reaction or astringent nature, which would coagulate the fibrin and albumen of the blood. My method of procedure is as follows: 1. The gentle removal of whatever fragments are lying in the uterine cavity, by means of forceps, care being taken not to tear from the walls any adherent piece. 2. The gentle flushing of the uterine cavity with the alkaline solution (100°), the reservoir containing the fluid being not more than two feet above the level of the hips. If the flushing could be continuously administered for a few hours (say two or three) the conditions would be more speedily reduced to normal, but the discomfort of the position of the patient (on a douche pan) prevents this, and a flushing once every two hours with one quart of solution is about the limit of treatment. For flushing the uterus, I use a small dilating uterine douche, and as there is plenty of room for the escape of fluid and fragments, there is no danger of fallopian colic or salpingitis. The first flushing is frequently followed by contractile pains and expulsion of any previously adherent pieces, together with much of the mucus. A tablet of Ext. Cannabis Indica.. gr. gr. every hour till desired effect is produced will contract uterus and alleviate pain. The bowels should be moved freely, both by enema and catharsis. During the interval between douches, the patient should be kept on her back, with the hips sufficiently raised to permit the retention in the vagina of as much of the alkaline solution as it will hold. The rapidity with which this treatment will reduce temperature, relieve pain, stop vomiting and remove offensive odor is marvellous to one who has not tried it. Sometimes two flushings are sufficient to cleanse the uterus thoroughly; vaginal douches being all that are needed subsequently to complete the work. Uterine congestion is speedily relieved, and the uterine discharge changes from brown, thick, bad smelling mucus, to a thin transparent one, accompanied or followed by more or less of a flow of blood. A reduction in the frequency of the flushings is desirable as soon as a tendency to return to normal conditions begins to be observed, as it frequently will within twenty-four hours. Then simple vaginal douches every three hours with an occasional uterine flushing if symptoms indicate it. The action of exosmosis (and endosmosis, for there is every reason to believe in the absorption of some of the fluid) is what is desired to relieve the existing congestion, as in a bronchitis, pneumonia, congestion of kidney, congestion of any mucous membrane, etc., and is the most rational means of restoring to normal condition. I do not wish to be understood as decrying the use of that most valuable instrument the curette, but only the abuse of it, to wit: its employment under such conditions as make it practically a sharp weapon loaded with septic matter, dangerous beyond the poisoned arrow of the Malay, or the fang of cobra, and utterly opposed to our modern ideas of antisepsis. 2 Macon Street, Brooklyn, N.Y. BY H. S. HUTCHISON, M.B. I. INTRODUCTION. THE MEDICINE OF ANTIQUITY. The study of the history of medicine has ever been a source of delight to the master minds of physic. By Hippocrates the Great, and through all ages, we find the physician urged to devote attention to its pages. The noble light which it casts upon the profession of the past, the opportunities which it affords of placing on their proper relative bases the currents of thought of the present day, and the grand examples which it contains of the heights reached by the earnest development of human resources, are all factors which render intelligent consideration of it a positive duty. Each year, at the present time, much new and pleasurable reading is published, dealing for the most part with single phases in this history, and this fact may make of interest a series of brief outlines of the periods of medical thought and activity with short references to the great men of each, culled from the rather extensive works on the subject and arranged in consecutive order. The medicine of antiquity, that practised before the age of the Roman Empire, differs from subsequent systems in one great essential. It was theurgic. Though guided by influences of divinities of various sorts, however, a link of interest with the past is formed for us by the fact that there seems to have always been a middle man to supply the demands of human nature, and this individual's relationship with his sick fellows resembles surprisingly the rôle filled by the physicians of the present day. The peoples whose medical development took place along such lines include the Egyptians, Indians, Babylonians, Medes, Persians, Jews, Chinese and Japanese. Owing to the association of religion with the art of healing in all instances but the last two, the actual workers in the field were, in the first place, priests. Hence with some nations, as in the case of the Levites amongst the Jews, men of one caste alone were entitled to follow the paths of medicine. It is certain, however, that such men devoted their best energies towards their medical rather than their priestly work, and as the race progressed a separation invariably sprang up between the two fields, until with the fuller ripening of the people a gradual specialism appeared amongst its doctors. Thus we read of herb-doctors and knife-doctors, the names of men famous as oculists have been preserved to us since the time of ancient Egypt, and we are assured that later still there were physicians |