Robert T. Morris advocates covering of all abraded surfaces with dithymol-di-iodide, claiming that the powder is insoluble in serous exudate, and that in conjunction with coagulated lymph forms a protective covering. The same author advocates the use of cargile membrane, claiming that it does not allow of suppuration, causing slight disturbance of the peritoneum and soft adhesions which are absorbed in a short time. It is now universally admitted, that the use of the most antiseptics in the peritoneal cavity, through their irritation of the endothelium of serous covering, predisposes these surfaces to infection and subsequent adhesions, hence they should not be made use of. As all blood-clots invite infection and may become organized tissues, they should be thoroughly removed. When working in the pelvis the Trendelenburg position should be utilized; as the position removes the upper abdominal contents from the field of operation, thus lessening the traumatism and shock due to handling. Only ligatures of an absorbable nature should be used within the abdomen, as when silk or ligature of a similar nature are used they frequently form a nucleus for future trouble. In the operation for the removal of pus tubes should the tubes be excised clear into the cornu of the uterus. If we fail to do this we frequently leave an area of infection

behind.

When ligating a vessel do not combine an unnecessary amount of tissue in the ligature, but rather ligate the vessel separately. It is not essential that ligatures should be draw so taut as to strangulate the tissue. In the closure of the peritoneum I follow the plan of everting the cut edges of the peritoneum. In this manner of closure we leave no raw surface projecting into the abdominal cavity, thus minimizing the danger of the formation of an adhesion at this point, as so frequently takes place.

The after-treatment of these cases is of paramount importance in preventing the formation of future adhesions. The abdominal straps or binders should not be too tight, as they have a tendency to compress peritoneal contents, thus favoring adhesions. These patients should be allowed to change their positions at frequent intervals; early catharsis should be sought as early peristalsis antagonizes the formation of adhesions. In all these cases the period of actual bed confinement should be much longer than is ordinarily insisted upon by the average surgeon of today. All peritoneal adhesions do not demand radical procedure, as adhesions that are soft in character may be absorbed. Again adhesions frequently exist between the intestines without causing any discomfort or interference with their function. But where the adhesions demand attention they are best treated by ligation and covering of the stumps with peritoneum where possible.

Where the abraised surfaces are too extensive to allow of covering with peritoneum I use the actual cautery, as this method combines both speed and disinfection, also the smearing tends to leave a smooth surface. In conclusion, let me say that I am thoroughly convinced that as we intelligently educate ourselves to the study of the causes of post-operative peritoneal adhesions, existing in patients on whom we have apparently performed a skillful and successful operation, the moré need we will find for intelligent prophylactic measures, and the more gratifying will be the results of surgery, both to the patient and to the operator.

HEART DISEASE IN OBSTETRIC CASES.

Mary Strong, M. D., Omaha, Neb.

Demonstrator of Obstetrics, Creighton Medical College.

ETER says a woman with heart disease should not marry; if she is married she should not become pregnant; if she has passed through one or two pregnancies safely she should not again become pregnant; and finally if she gives birth to a child, she should not be allowed to nurse it.

Etheridge, in Jewett's Practice, considers these statements altogether too sweeping, and thinks they should be applied altogether to severe valvular cases.

Certainly a strict following of these rules, even if practicable (and we know they are not so), would result in a considerable decrease in population, for some degree of valvular defect, especially mitral insufficiency is relatively common.

At the Rescue Home, where if possible we receive patients early enough to thoroughly examine and treat abnormal conditions I have found considerably over 5% affected with heart lesions, most of them having a mitral regurgitant murmur. A marked accentuation of the second sound of the heart is also not infrequent, but really bad cases of heart lesion are not so common. Yet by the use of common sense in hygiene, diet, work and in the management of labor, we never have lost a woman there yet since I have been physician, over seven and one-half years, and most of them have delivered themselves.

Now of course we have a great advantage there in being able to control the prospective mother. But in private work, one can do something in this line if engaged for a case two or three months ahead, as is desirable. It has seemed to me that valvular disease was more common in women who came from the country districts and do considerable out-ofdoor work.

Patients will deny having had rheumatism, tonsillitis, etc., but by close questioning you may elicit the fact that they have had so-called growing pains in childhood. If growing pains are reported always look for valvular disease. The worst case of heart disease we had denied all the usual causes of her trouble, but finally remembered having growing pains when a child. This woman had mitral and aortic lesions, also attacks of angina pectoris. Yet she lived and her baby lived also. I shall refer to this case later.

Unless the

Treatment.-I think this should be largely hygienic. heart shows marked signs of break down, the prospective mother should work in moderation every day for several reasons: First, to keep up the muscular tone of the system; next to keep down the size of the child; and lastly, to promote early engagement of the head in the pelvis.

Next in importance is diet. Very little, if any, meat do I allow. In heart cases we are always liable to have sudden attacks of renal insufficiency, even anuria. Give plenty of fruit, but do not allow much indulgence in sweets. Hardly anything can be worse for these cases than to Toll about on a sofa and be stuffed with meat, eggs, etc., to keep up their

strength. But I fully realize that these things are very hard, often im. possible to regulate in private cases.

Medicinal Treatment.-First of all keep the bowels open, and in an ordinary case, if the patient will take it, I think there is nothing better than the cheap, nasty, old-fashioned epsom salts. This can well

be combined with potassium bitartrate, the ordinary cream of tartar, which much improves the taste of the mixture, and promotes kidney action. If on examination I find a hard, wiry pulse, with or without marked exaggeration of the second sound of the heart, nitro-glycerin, either in tablet or solution, has done me the best service. About 1-100 minim is enough at a time, but the number of doses vary from three a day to one every two hours, according to indications.

If the heart seems weak, give digitalin. Why any body with any common sense at all should talk of giving the nauseous infusion of digitalis when the stomach is irritable from the pregnancy and very likely congested from the effects of the heart lesion, is more than I can see.

Digitalin tablets, gr. 1-100, given two or three times a day, very rarely disturb the stomach, and they do tone up the heart. Often the use of both these remedies is better than one alone. Nitro-glycerin seems to counteract some undesirable effects of the digitalin.

But we sometimes get bad cases where accommodation fails, the stomach refuses food and possibly anuria occurs. Here calomel in decided doses, 6 to 10 gr., is good. Of course calomel is risky in pregnancy, but we must sometimes choose between a risk and a dead certainty. And saline enemas will usually promptly aid in relieving the anuria. I will report two cases:

CASE I.-G., a frail, delicate woman who had had valvular disease some years was brought to the Home about seven months pregnant. For about a month she did pretty well on the treatment I have outlined for ordinary cases, but suddenly, to use the words of my friend Dr. Mack, who kindly saw the case, her heart went all to pieces, stomach refused food and there was complete anuria for twenty-four hours. The case looked pretty bad, and Dr. Mack expressed his satisfaction that it was not his case. But a big dose of calomel settled the stomach, a pint of normal saline by enema every two hours and 1-100 nitroglycerin also every two hours soon got the kidneys to acting freely. Next day she could take milk, and after a few days we cautiously returned her to the light diet she was previously on. A friend had asked me to call him when I had a bad confinement, and this seemed just about the article. But one night I was hastily called, as G. was sick. I lost no time in getting there, but on entering the yard an infant voice was loudly announcing its arrival. G. had a very rapid, easy labor and a normal convalesecnce. I did not allow her to nurse the child, though at first the lacteal secretion was abundant. I think the saline enemas were what overcame the anuria. There never was much albumin in her urine, just a trace.

CASE II. The case already mentioned as having a double lesion and angina pectoris had a harder time. I put her under morphine, atropine 1-100 and strychnine 1-20, beside nitroglycerin at the time of labor and delivered by forceps as soon as the os was dilated, allowing no bearing

down efforts at all. She had a slow convalescence, but finally got up and went home in pretty good shape.

Is there a surgeon

Some authors advise chloroform in such cases. here who would want to give it to a patient with a heart like either of these? I knew of one woman in the north part of Omaha who died undelivered from this cause. In the last case I reported I confess I had a knife ready for post-mortem Cesarean section had the mother died.

Women whom I have delivered by forceps after the free use of morphine and atropine have told me they hardly felt the pain though it seems to increase uterine contractions in the second stage of labor. Of course it is given hypodermatically.

I have never tried scopolamine, as some very unfavorable reports of its action have appeared in the medical journals. Atropine seems to be

safer.

Some writers advise the induction of abortion or premature labor in such cases. As an anesthetic is likely to be essential if this is done, it seems more dangerous than to allow the child to go to time. Of course this means when there is no disproportion between head and pelvis. I have already alluded to the importance of exercise and diet to keep the child small.

Conclusion.-The essentials seem to be dieting, exercise, keeping the bowels free, nitroglycerin or digitalin (or both), calomel and saline enemas with milk diet and rest if accommodation fails, and at the time of labor, morphine and atropine, with strychnine, if the heart seems weak, and prompt delivery by forceps unless the second stage be very rapid and

William F. Waugh, A. M., M. D., Chicago.

T is a common observation of men accustomed to horses that if these animals are fed long on corn they become too lively to be readily managed. Why is this? What is there in corn that renders it more stimulating than other foods? Neither the starch nor the gluten differs specially from those of other grains. It seems that for any distinctive principles we should look not to the body of the grain, but to the germ, since the former is simply a store of the ordinary food elements.

Procuring a bushel of shelled corn, a number of girls were set to work to extract the germs, since this part of the grain does not separate in milling as does that of wheat. From the extracted germs our chemist, Dr. Clay, extracted a substance which we know as corn nuclein, since it resulted from the processes ordinarily employed for the extraction of nucleinic acid. The yield is very small.

The product does not seem chemically dissimiliar to nuclein from other sources, though one analysis revealed an extraordinary proportion of phosphorus, but that its action is different, more strongly excitant or stimulant as above, there is no question.

A physician, 72 years of age, came to the writer for treatment for a neurasthenic malady, with general depression. In the course of the treatment I gave him a few drops of this corn nuclein without saying anything about it to the patient. Two days later he complained to me that something was exciting his sexual functions beyond his power of control. The corn nuclein was discontinued and all other treatment continued, and the unpleasant effect subsided. Two months later, desirous of ascertaining whether the sexual stimulation was accidental or at all dependent on the nuclein, I slipped a few drops into his medicine without mentioning it to him or anyone else. The next day he turned on me angrily, and said: "You are giving me that damned stuff again. I told you I could not stand it and I want you to stop it at once. I stopped it, and the erotic. irritability at once subsided.

Not being in general practice my opportunities for similar trials are few, but several have come my way, and in each the same result has followed. But these are too few to base on them any definite conclusions, certainly not to present this as a remedy for impotence. Besides, the expense of the product is so great as to remove it from the category of ordinary commercial exploitation, as anyone can soon satisfy himself who undertakes to extract the germs from a bushel of corn, or to pay for having it done. My object in presenting the matter is to emphasize my contention, frequently made, that there are treasures in the vegetable materia medica of which the medical profession scarcely dreams, which await the investigator, armed with modern methods.

A

TUBERCULOSIS OF JOINTS.

T. E. Potter, M. D., St. Joseph, Mo.

ITH but few exceptions fungus inflammation of joints is tubercular, and is far more common than is usually supposed. Names given to such troubles are known as chronic fungus arthritis, strumous arthritis, and tumor albus.

Wiseman, who was one of the first to describe this character of joint troubles, says: "The swellings affecting the joints in this disease are of two sorts. Both of them are made by congestion and increase gradually, yet different, in that the one ariseth externally upon the tendons and between them and the skin, or between them and the bones; the other, internally, within the bone itself. That which ariseth externally affecteth the ligaments and tendons first, and sometimes relaxeth them to such a degree that the heads of the joints frequently separate from one another and the members emaciates and grows useless; but, for the most part, the tumor, over-moistening the ligaments and tendons produceth a weakness and uneasiness in the joint raising a tumor externally and in progress the membranes and bones are corroded by reason of the acidity of the humor; yet it is much hastened if upon a supposition of dislocation they consult the bone-setters."