minds the very important fact that the ability of a physician to enter and leave a sick room acceptable to a patient, is of more importance as a factor to his success in practice than any superior medical knowledge that he may possess." 195 West Brookline Street. ALSTONIA CONSTRICTA. BY J. A. BURNETT, Hackett, Ark. [Written for the MEDICAL BRIEF.] There are but few, if any, drugs in the materia medica of greater therapeutic value than alstonia constricta; still it is almost unknown to most physicians. This remedy is not often mentioned by late works on materia medica. Potter says: "The Australian bitter bark, alstonia constricta, yields an alkaloid, alstonine, which resembles quinine in many respects. A tincture of the bark has slight diuretic and diaphoretic action, and has been used with benefit in influenza.” In most cases of colds, influenza, etc., I find alstonia to be a valuable remedy. It can be combined with calcium, iodized when needed, and the action of each remedy will be enhanced very much. Alstonia constricta can be obtained in three forms: the powdered bark, the tincture, and the fluid extract. In my practice I prefer the powdered bark, as it is cheaper and seems to give better results. Like quinine, it is best given in capsules. Next to the powdered bark I prefer the tincture, which gives good results. The fluid extract can be used when desired. In all atonic conditions alstonia can be used with benefit; if there is a tendency to rickets, undevelopment of bones, teeth, etc., combine it with calcium phosphate, and in anemia combine it with iron carbonate. The action of alstonia resembles the combined action of cinchona and nux vomica, without being a toxic agent; so one can readily see it has an extremely wide range of therapeutic action. In fact, in my opinion, there is no drug in the materia medica that has a broader range of therapeutic usefulness than this one. In malaria, either acute, subacute or chronic, alstonia is a reliable antiperiodic, but is more adapted to the subacute forms. When using alstonia in malaria, the dose of the powdered bark varies from two to eight grains. I find that three or four grains, given every two hours until four or five doses are taken, beginning so the last dose will come about two hours before the chill is due, will in 99% of cases prevent the chill or keep it off. In mild cases, four doses, two hours apart, of two grains each, will prevent a chill, while in stubborn cases as much as five grains, or even eight grains, should be given every two hours until four or five doses are taken, to prevent a chill. Between chill times, the dose can be given every three or four hours. This remedy has quite a little influence on the liver, but, like quinine in malaria, it should be preceded by some good purgative that will thoroughly arouse the liver and clean out the bowels. I often see some statement that some physician wants some remedy besides quinine for malaria; here it is. Any physician, no matter in what malarial district he lives, can take powdered alstonia constricta and use it as above in his practice without using a dose of quinine in any case. In malaria, where much stimulation is needed, powdered capsicum can be added to alstonia. I often put about one grain of powdered capsicum to each dose of alstonia. In chronic malaria, where the spleen is enlarged, use it with calcium iodized. Give five to ten grains of calcium iodized three to five times a day, or about the same amount of berberine muriate. Alstonia constricta is a valuable remedy in summer diseases of children, as it will sustain their vital forces, where the summer heat is depressing. It is one of the best remedies for diarrhoea when caused by indigestion part of the food passing without being digested. It is a valuable heart remedy and will sustain the heart in exhausted conditions, as in the later stages of pneumonia and typhoid fever. The effect that alstonia has on the liver is very limited, but it will, in the course of time, clean a coated tongue, especially when there is a tendency for it to be coated all the time, or when it has cleaned off in patches. When purgatives have been given and a tongue cleans off in patches, it shows atony, and the patient will be rather slow in recovering; in most of these cases. alstonia will be of great value. I fully believe that alstonia constricta is one of the best remedies we have for typhoid fever. It will not abort a case at all, but will sustain the vital forces, heart, etc., and cause it to run a mild course, and there will be a quick convalescence. Its diuretic properties will prevent all tendency to uremic poisoning, and its general antiseptic systemic effect is, in my opinion, far superior to echinacea in this dreaded fever. Dropsical conditions that occasionally follow typhoid fever are prevented where alstonia is used. Of course, alstonia is not the only remedy needed in typhoid fever, but it will be needed, or can be used, in some part of all cases. The action that alstonia has on the nervous system is somewhat similar to that of cinchona and nux vomica, which makes it a powerful nervine. In many ways the general action of alstonia very much resembles the action of myrica cerifera. Alstonia constricta is a non-toxic agent, but when given too freely it will cause unpleasant head symptoms, similar to large doses of quinine. Some authors place the dose of the fluid extract as much as one drachm, while the same author will place the dose of the powdered bark at eight grains, which I do not understand. Again, some authors place the maximum dose of the fluid extract at eight drops. Alstonia has an alkaloid, called alstonine or chlorogenine, which can be obtained on the market, and has similar properties to alstonia constricta, bearing about the same relation to it that quinine does to cinchona, or strychnine to nux vomica. The common name for alstonia constricta is Australian fever bark, as it is a native of Australia. The name alstonia was taken from Chas. Alston, a Scotch botanist (1683-1760). There are several species of alstonia; the dita bark; alstonia scholaris is often used in medicine, and somewhat resembles alstonia constricta, but should not be used as a substitute for it. I am not aware of any other species of alstonia that has been placed on the market for the use of medicine, except these two varieties. For further information, I will refer the readers to my articles, "Alstonia Constricta," page 126, June, 1908, Physician's Drug News; "Alstonia Constricta," September, 1905, Medical Summary, and "Alstonia Constricta," May, 1906, Medical Progress. TREATMENT OF AN INGROWING TOENAIL. BY DR. VON NOPPEN, Niles, Mich. Drench a cotton thread in a solution of potassium carbonate (1:4) and press it between the upper surface of the nail and the usually fungous granulations. The solution soaks the upper cells of the nail and changes them to a paplike mass. The thread always remains moist and every day you can scrape off the softened nail until the remaining part in a few days is so pliable and thin that without the least bit of pain you can cut the necessary amount of nail off. It is better yet to use the solution until the ingrowing part of the nail has entirely disappeared and go ahead this way until the ulceration under it is cicatrized. In the last case you are safe from a recurrence. NITROGLYCERIN IN NEURITIS. Dr. Stevenson (Medical Record, May, 1908) reports good effects from the nitroglycerin method of treating neuritis according to the Krauss method, beginning with 1:100 of a grain every eight hours, reducing the interval one hour in every twenty-four until the full physiologic action is manifest. PRE-NATAL ULCER OF THE SCALP. Riviere (Gazette hebd. des Sci. Med., December, 1907) reports an infant born with ulcer of the scalp, not caused by syphilis and not due to instrumental delivery. It was pre-natal, an arrest of development. It readily healed under local treatment. SOME PRACTICAL OBSERVATIONS UPON PLACENTA PRAEVIA AND ITS MANAGEMENT. BY J. H. HIDEN, M. D., Pungoteague, Va. [Written for the MEDICAL BRIEF.] It is held by statisticians that one case of placenta prævia occurs in about one thousand pregnancies, and one of puerperal eclampsia in about five hundred. In view of such statements, were I at all superstitious, I would doubtless wonder if the infernal demons of the Apostolic age had not conspired against me; for I have had, within a few months, four cases of puerperal eclampsia, and three of placenta prævia, besides a number of other obstetrical abnormalities of less grave import. The successful management of all of them, nevertheless, has brought me ample compensation; for it is mostly by such experiences that one can hope to acquire any marked degree of skill in this line. Assuming that the reader is, more or less, familiar with the commonlyaccepted teachings of the cause, pathology and symptomatology of placenta prævia, I shall confine myself mainly to its management. And so, before going further into details, it may be well to take a glance at placenta prævia as it is usually thrust upon us, and then review, in a "nutshell" some of the methods in vogue as to its management. Unfortunately, many of these cases are not seen by the family physician until they have assumed a more or less grave aspect. Hemorrhages of an alarming character sometimes occur before the physician is consulted. I have had this to occur in my own practice on two occasions. As the appearance of hemorrhage is liable to occur without the least warning, it is evidently of supreme importance that the physician should be thoroughly familiar with the most reliable methods of controlling it, while inducing labor, or completing the process of delivery. If called to see a case which has sufficiently advanced in pregnancy to make it probable that the twenty-eighth week can be reached without undue risk to the mother, delay in radical treatment may be permissible, as the child's life is certainly worthy of consideration. By adopting this plan, on two occasions, I have saved mother and child in each case, all four of whom are now living. The extremely narrow escape of the mother in each case, however, has deeply impressed me with the additional risks which she encounters when such measures are adopted. In any case in which it is thought advisable to follow the course in question, it is well, upon the appearance of hemorrhage, to put the patient to bed, and pack the vagina with sterilized tampons, more or less saturated with some styptic. A supply of these tampons should also be left with the patient, with minute directions as to how they should be used, in case they are needed in the physician's absence. When the age of the child's viability is reached, bold action should be contemplated, and one of the following methods usually adopted: I. Wigan's Method-This consists in packing the vagina with cotton balls or tampons, and placing a rubber bandage over the vulva, so as to secure a constant pressure against the uterine cervix from without, while the child's vertex presses upon the internal os from within, thus allowing but a very limited space for bleeding. The method is, evidently, suited to vertex and breech presentations only, and then only in those cases in which the placenta do not extend beyond the border of the uterine os ("marginal" cases). I doubt the wisdom of extending its application to a much wider range. Barnes' Method-By this plan the physician passes his hand into the vagina, and then two fingers into the uterus, insinuating these between the uterine wall and the placenta, and sweeping them around in a circle, so as to complete the separation of that portion of the placenta near the uterine os, thus favoring retraction of the relaxed tissues, and contraction of the bleeding vessels. The remainder of the treatment may be followed with further dilatation of the uterine os, and version; or, in case bleeding is sufficiently controlled, the case may be conducted in a normal way. 3. Cohen's Method-By this method the physician passes one or two fingers between the placenta and the uterine wall, on the side where separation has begun, or where there is least resistance, and completes the separation on this side. When a sufficient portion of the placenta is thus separated, he pulls down this flap through the uterine os, and packs it against the other side of the cervix. Then he ruptures the membranes, gives ergot, and hastens the process of delivery, so that the vertex may quickly engage that portion of the os from which the separation has taken place, and by direct pressure control bleeding. If this is unsuccessful, podalic version is then performed. 4. Simpson's Method-This consists in separating the entire placenta from the uterine wall, and extracting it. This procedure often stops bleeding by the retraction of the tissues, which usually follows, but it gives scarcely a possible chance for the child's life, and, hence, is recommended only in those cases in which there is practically no hope for the child's life by any other process of delivery. 5. Hofmeier's Method-This is facilitated by the fact that the placenta is usually quite thin in placenta prævia. It consists in forcing the finger directly through the placenta, and then bringing down a leg through this opening, thus completing version. This method has given remarkably good results. My first experience with placenta prævia was about ten years ago, when I was called in consultation by another physician. We were both young and inexperienced practitioners, yet full of hope, and anxious to make for ourselves a reputation. We made it, but not as physicians. When we saw our patient approaching term, with the bed almost saturated with |