talk about expectorating in public places is necessary, if we are to mitigate the misery this malady can inflict on the community.

Treatment. For obvious reasons, and on account of what has already been said, the patient should be advised to go to bed and stay there. I think it is also desirable to state plainly to the patient our reasons for this. It is more likely that the advice will be followed if we do so. I generally advise that no nourishment be given under ordinary circumstances until there is a distinct desire for it. In gastric cases my patients have been ordered to fast for several days. Clifford Allbutt recommends, in the Lancet of May 13, 1905, what he calls a non-toxic dietary (excluding meat) during the long convalescence, but I confess I do not understand the rationale of it. With regard to therapeutics, I always precede drugs by one or two cold packs when there is high fever, with beneficial results, especially in children. Most writers condemn the general use of antipyretics in this disease, from their depressing effect. For myself, I never hesitate to use them, but always in small doses, which are directed to be taken every one, two, three or four hours, according to circumstances, until relief is got, or until four doses have been taken. There is no way to give relief so quickly as by the use of phenacetin or phenazone combined with citrate of caffein, sal. volatile, and spirits of chloroform. Occasionally I prefer to use the time-honored Dover's powder, especially where the pains are neuralgic and the fever not high. Sometimes a diaphoretic mixture is sufficient, but it is not so if there is much pain, as is so frequently the case. I use such to fill the gaps in the treatment by the coal-tar derivatives. Aspirin I find of great value in the high temperatures that accompany pneumonic complications. Bromides are sometimes essential to relieve nervous irritability and depression with the sleeplessness that accompanies these states. During convalescence I give cinchona, nux vomica and hydrochloric acid, but, after all, time is the great healer.

ACETYL-SALICYLIC ACID IN INTRACTABLE VOMITING.

Dr. W. M. Crofton, in La Semaine Médicale, reports very favorably on the action of acetyl-salicylic acid in intractable vomiting in pregnancy, even where all other remedies have failed. This remedy is also useful in similar cases of tuberculous peritonitis. The Doctor recommends that five to ten grains of acetyl-salicylic acid be administered just before meals. The beneficial action of the new remedy is immediately observed; in some cases the vomiting ceases after the first administration of the powder, in others after several repasts with the specified dose of this remedy.

APPENDICITIS-A QUERY.

BY C. H. NEWTH, M. D., Philomath, Oregon,

[Written for the MEDICAL BRIEF.]

What is the cause of so many deaths after operation for appendicitis, in doctors? The American Medical Association Journal publishes each week, as far as known, every death of doctors in the United States, also the cause of death, if possible.

During the year 1906 there was recorded two thousand one hundred and fifty deaths. But of these only one thousand three hundred and ninety-eight gave the cause of death. Of this number one died of appendicitis, and twenty-six, just two per cent, died "after operation for appendicitis." Now, it is not conceivable that of all deaths in adults, or adult males, two per cent of deaths are after operation for appendicitis. What, then, is the cause of this awful mortality? It would be very interesting to know how many of these would have died if they had not been operated on. It would also be interesting to know how many got well after operation. It was not, in many cases, that they died because the operations were not competent. That bright young man, Dr. Pilcher, of New York, who was taken down with the disease while away from home attending the Boston meeting of the A. M. A., was operated on as soon as the most eminent surgeons considered it best, and by the best operators in the country, yet he helped to make the number. Statistics do not show as large a mortality. Why is it?

I think these figures at least show that there are a large number operated on that would better wait a few days. If doctors would only get the idea out of their heads that if a person has appendicitis, the only thing to do is to sit down and watch the case for twenty-four hours, and then operate if the patient is not moribund, there would be fewer deaths from operation. We are beginning to realize that appendicitis is often a medical, and not surgical, disease.

There is no doubt but that the proper thing to do first in a case of appendicitis is to thoroughly clean out the bowels. Epsom salts or castor oil is the best for this purpose, unless there is vomiting, and everything. is rejected by the stomach; then small doses of calomel, every half hour until the stomach is quiet, will be better. In twenty-four hours, if, by using hot applications and counter-irritants, there is improvement, and the fever is reduced, or gone, it is safe to operate, but generally not necessary. If, however, the pain and fever has not abated, and the look of distress is worse, an operation will often be needed, but is not now safe. The best counter-irritants are chloroform first, then follow with turpentine stupes; iodine on hot, wet cloths, wrung out of vinegar and salt, or simple hot water, or water medicated with epsom salts or boric acid. These cloths

should be kept hot, not by removing and wetting again, but by applying very hot plates upside down, over the cloths, and changing as often as necessary without moving the cloths. The wet application should be constantly kept hot enough to feel uncomfortable to the patient. Some authorities recommend ice, but I think there is no doubt but that sometimes ice does damage; makes the case worse, and is never as beneficial as heat, if applied thoroughly. After a busy practice of over fifteen years, without a death from appendicitis, I have become imbued with the idea that an operation is not always absolutely necessary to save life. None of my cases have been operated on, yet all are now alive with one exception, who died five years after her attack, with no symptoms of her original disease. Also two cases that I am now treating. There has also been but two recurrences. Now I do not mean to imply that none of these cases needed operation; several of them needed it bad, and would have been operated on if it had been possible; but in all the cases it was impossible, either on account of circumstances or opposition on the part of relatives. One case especially, I remember, that was brought sixty miles over the mountains from the sea coast before he was seen by a doctor, and after a week there was indefinite symptoms of abscess, and arrangements were made to operate next day. But early next morning the father came in, three miles from the country, and said the boy was well, and was up and around with nothing the matter. He was cautioned of the danger, but insisted that the boy needed a doctor no longer. But in another week I was called, and found a large abscess, with temperature of 104° F. I prepared the boy for operation, but was too late, for the boy passed over a pint of pus, and the tumor went down, and the boy got well, and stayed well. This does not show that it is best to wait for the abscess to break, but it does show that it is not always death to wait. We read every day of experiences similar to these, and, really, every death I know of in the practice of other physicians comes in one of three classes: Either they died before help reached them, or they were operated on, or they were moved a long distance. We all know that a man has a better chance of recovery with intelligent treatment and absolute quiet than he has with an operation at the end of a long and jolting journey.

Summary-Ninety per cent would recover without abscess if treated by thorough cleaning out of the bowels, followed by several days' fast and hot applications. Ninety per cent of abscess cases would break into the bowel, if treated as above, with prolonged fast and absolute quiet. But every case showing symptoms of abscess or perforation should have the benefit of operation at the proper time. Yet, even then, simply opening the abscess, as was done in the case of King Edward, of England, is sufficient, and is better and safer than a more extended operation.

Now, one suggestion, and I have done: This is written by a country physician with a practice amongst country people, and not amongst people

broken down by unhealthy surroundings, debilitated by whisky and venereal disease.

I spent several months in post-graduate work recently in New York and London, and it is a fact that almost every patient had venereal disease at some period of their lives, while at home not one case in five hundred has ever had syphilis. Some people think that catarrhal appendicitis can never be recovered from without an operation, but I do not see why it should not, as well as catarrhal jaundice, or catarrh of the bile ducts. In my experience it has always got well with proper medication.

THE ABORTION AND MODIFICATION OF CROUPOUS PNEUMONIA. BY ROBERT C. KENNER, A. M., M. D., Louisville, Ky.

[Written for the MEDICAL BRIEF.]

Consultation of the leading works on the practice of medicine will reveal the fact that most of the authors regard croupous pneumonia as a self-limited disease.

Regarding self-limited diseases, I may say the term is very vague. It conveys the idea that no treatment can be instituted that will modify the disease process, and that it must necessarily follow its course. Such an assumption is rarely true. Of course, many morbid processes require such therapeutic intervention as is not yet "dreamed of in our philosophy," but it is indisputable that many affections not capable of cure may be so modified as to permit of the recovery of the patient. This is capable of demonstration in diseases attended with pain and other severe manifestations, which are within the sphere of our therapeutic capabilities.

Croupous pneumonia is a disease which has been considered by many as a self-limited disease. The late Prof. Austin Flint-one of the greatest clinicians which America has produced-expressed his belief, in one of the editions of his work on practice, that pneumonia might be aborted. Other good observers hold this opinion. A clinical study of croupous pneumonia, extending over twenty-five years, has convinced me that the affection is capable of abortion or favorable modification, if seen early. If seen early I believe the disease can be brought to a quietus in twenty to thirty hours. Seen after the process has gone farther, we may often modify the affection.

Let me define the terms here used. If called to a patient who lately has been seized with a chill, who has pain in the side, with or without cough, and a fever of 103° F., coupled with rapid breathing and a history such as would lead one to expect pneumonia, I believe it is quite possible to abort the disease. Of course, I desire to be clearly understood that the physician's visit must be made and the treatment must be brought to bear within two hours from the initial chill. Seen after that time and before ten hours shall have elapsed since the initial chill, it is, I think,

often within our power to favorably modify the pneumonia process. By this I mean that the clinical picture of croupous pneumonia may be so changed that the process will be of short duration, lasting four or five days often, and being essentially mild.

My experience has confirmed these beliefs, and I have studied my cases with the greatest care, in order that I might eliminate erroneous conclusions. I have drawn my conclusions, too, from a study of an extended number of cases, and therefore feel that my convictions are founded upon correct deductions.

As for the means employed to abort or modify pneumonia, I give, with but slight modification, the following treatment: Children, very old or debilitated patents, will, of course, require smaller dosage. Of course, the judgment of the physician who studies the case in hand will lead him at once to a correct comprehension of the limitations and the modifications of the treatment, if such are deemed necessary.

Immediately after examination of my patient, and I am convinced that pneumonia is developing, I give an hypodermic injection of onefourth of a grain of sulphate of morphine. In ten minutes I administer thirty grains of sulphate of quinine by the mouth. I have the patient assume the recumbent position and remain as completely quiescent as possible. In eight hours, if the patient has any elevation of temperature, or if physical examination indicates any signs of the disease, I repeat the quinine, giving same dosage.

Of

The same means are employed to modify the pneumonia process. course, when the second dose is given and there is yet evidence of the disease after a lapse of another eight hours, we may assume failure to abort the affection; but if the treatment was instituted early enough we shall find in most cases the process has been modified and that the disease has been rendered essentially mild. Then its treatment is to be conducted on customary lines.

The administration of morphine prior to the exhibition of the quinine generally insures quiet, and no vomiting occurs. Still, unfortunately, this sometimes happens. In such an exigency it is best to give another full dose of quinine and to apply a mustard plaster to the epigastrium. It is unwise to allow these patients to imbibe any fluids for four or six hours after the abortive treatment has been instituted. Patients, as already observed, should be required to keep quiet, and should not talk or make any but the most necessary movements.

The after-treatment of these cases should be, in my opinion, conducted on the principle that the general system is below par. In attaining this end, malt extracts and cod-liver oil; the oil, plain or in emulsion, is inferior, in my opinion, to the palatable preparations which are composed of the extracts from cod-livers and wines. These are not only meritorious, but they are readily taken by patients.