litigation discouraged, but professional carelessness, indifference and incompetence would become less common, and besides the consciences of some expert witnesses would be relieved of a very considerable strain. That I may not be charged with being unfair or making my condemnation too comprehensive, I wish here to bear cheerful testimony to the fact that I have met with some medical experts who testified for their colleague in the very case to which I have referred, and who gave every indication of being honest and conscientious in their testimony; but the fact remains that the generality of the profession is unfortunately open to the criticisms heretofore made, and the sooner these gentlemen see the error of their ways the better for the honor of the medical profession. They are sadly mistaken if they believe that the community is deceived; the esteem in which expert testimony is held by the public at large shows the people are very wideawake. I, therefore, commend these lines from Burns to the consideration of the experts: Oh! would some power the giftie gi'e us, To see ourselves as others see us. Fullerton Building. [Written for the MEDICAL BRIEF.] Proctitis and Sigmoiditis. BY R. D. MASON, M. D., Professor of Rectal and Pelvic Surgery in the Inflammation of the different mucous membranes are very common and manifest their presence in different ways, according to the part affected, and whether acute or chronic. The causes that will produce the disease in one place will do so in another. A sudden chilling of the body may cause a so-called cold in the head, and sleeping on cold, damp ground may cause a proctitis, which if left untreated may become chronic, and we have the chronic diarrhea so often found among elderly people, especially old soldiers. There may also be a specific inflammation of the rectal membrane, generally due to indirect causes, as diphtheria, gonorrhea, etc., accidentally carried from some other part of the patient's body to the anal or rectal membrane by means of instruments, fingers or syringe nozzles, or by the discharge from the vagina flowing over the parts. Among the causes, in addition to those already mentioned, probably the most common one is traumatism, either from within or without. From within serious injury may be the result of substances swallowed, as pins, fish bones and other foreign substances. All such things will pass through the stomach, small and large intestines without difficulty, but lodge in the rectal pouch and set up an inflammatory process that may result in a general proctitis or possibly an abscess. I have frequently taken such things from abscess cavities in this region. The disease may also be caused by the retention of hard, dry, impacted fecal matter, which is very irritating. Those causes which act from without are contusions and punctured wounds. It is not very uncommon to have the bowel wall punctured by the rough use of instruments or the finger in making an examination. In a recent issue of the journal of the American Medical Association, Dr. Howard Kelley cites several cases where the wall of the bowel was punctured by the examining finger. This is more likely to occur in old people. In case such wounds are uncared for a proctitis or peri-proctitis would result that might prove fatal. Kelley says such wounds should be repaired by opening the abdomen and stitching from the peritoneal side. Owing to their being so low in the pelvis it seems to me that this would be extremely difficult to do. In the chronic form of the disease, in addition to the rectal inflammation we almost always have an extension to the sigmoid and the whole descending colon may be affected. In acute proctitis the pain is very great and is accompanied with tenesmus and considerable constitutional disturbance. There is a constant feeling that there is something more in the bowel, even after the patient has just left the commode, but this is due to the swollen mucous membrane. When the disease becomes chronic there is not much pain, except on deep pressure over the sigmoid. The desire to go to stool, while not constant as in the acute form, is still very troublesome and there may be from ten to twenty bowel movements daily. This takes place more often in the morning rather than any other part of the day, and it is not uncommon to have four or five bowel movements in rapid succession containing bloody mucus or clear mucus resembling jelly and followed by a solid stool. The patient may then pass the rest of the day with but little discomfort. In its early stages it is difficult to diagnose the disease from cancer of the sigmoid, but as the latter is essentially chronic, while cancer runs its course in two or three years, and as the sigmoiditis does not, as a rule, come under the doctor's care until it has run for some time, the diagnosis is not hard to make. A microscopical examination of the discharge should be made to differentiate between the common inflammations and amebic dysentery. As the amebæ are not active in cold solutions the examination should be made while the matter passed is still warm. In the chronic form of the disease the membrane of the sigmoid, when examined through the sigmoidscope, has a very dark appearance and looks like fresh, raw beef, and in some instances blood may be seen oozing from the bowel wall. Treatment in the acute form consists in rest to the inflamed part, a carefullyselected diet, and the use of mild antiseptic astringent solutions. The one great difficulty in treating proctitis is the lack of drainage. The products of inflammation are retained behind a tight sphincter muscle and the greater the inflammation the more firmly does the muscle contract. This is true to such an extent that often it is only with the greatest difficulty that a bowel movement may be had or an irrigator tube introduced. In such cases the patient had better be put under the influence of an anesthetic and the sphincter divulsed. In punctured wounds, where the bowel wall is torn and pus has formed, it may be necessary to cut the muscle posteriorly, so that proper drainage may be obtained. There is no one thing that assists Nature in bringing about a cure in a diseased organ that is acutely in flamed so much as rest. For this reason in acute cases the patient should be kept in bed and fed only highly-concentrated food, such as will leave practically no residue to pass away. In fact, if almost no food is given for a few days it will greatly assist in the cure. Another reason why the recumbent position should be insisted upon is that the rectum and sigmoid are drained by the middle and superior hemorrhoidal veins, which have no valves and go direct to the liver through the portal system, and when the patient is standing the weight of this entire column of blood has to be lifted by the heart, while if the patient is lying down gravity will greatly assist in keeping the parts from excessive congestion. A In the acute form it is not very common to have an extension to the sigmoid, and for this reason any injection used need not be forced above the rectal pouch. double current rectal irrigator should be used, or if this is not at hand an ordinary soft-rubber catheter may be introduced with the syringe nozzle for the return flow; by shutting off the outflow tube the rectal pouch may be filled to its fullest capacity. The remedy that has given me the greatest satisfaction is fluid hydrastis in twenty-five per cent solution. Weak solutions of zinc, copper, etc., are useful, as are also the new preparations of silver, in from five to ten per cent solutions. Silver nitrate should not be used in acute proctitis, except in very weak solutions. In order to control the constant desire to empty the bowel some local opiate is needed, and nothing is better than two or three ounces of starch water to which has been added from ten to thirty drops of tr. opium. This may be repeated as found necessary. Specific proctitis is not often seen and is generally due to gonorrhea. The line of treatment should be the same as that followed in treating the disease in other localities. The bowel should be irrigated with large hot permanganate solutions of from three to five per cent in the early stages. In the later stages of the disease astringent solutions should be used and a good formula is the following: B Zinc Sulph.. Bismuth Carb. Liq. Hydrastis (colorless) Aquæ Dest., ft......q. s. 12 grains. drachms. 2 One-half of this may be added to an equal quantity of water and injected and allowed to remain. In treating the chronic form of the disease we meet with a more difficult problem, as the sigmoid and often the descending colon are affected, and irrigations must be forced above the rectal pouch. Most writers on this subject advise the use of the long rectal tube, but I have found from experience that it is exceedingly difficult to introduce this instrument into the descending colon. I have used the utmost care in trying to do this and have congratulated myself that the tube was in almost its full length only to find that it was coiled in the rectum. My plan for irrigating the bowel is as follows: Have the patient lie on his back with the hips well elevated. Have the water very hot and the irrigator not more than two feet above the table; use a short nozzle, not more than three inches long; let the water run very slowly, and if the patient says he can not hold it, stop the flow until the desire for an evacuation passes away and then start it again. It is only the first few ounces that causes the desire for an evacuation to be felt, and as soon as the water begins to flow into the sigmoid this will pass away, as a rule. If the sphincter is very lax push the syringe nozzle through a small roller bandage and then into the bowel and sufficient pressure may be made against the sphincter to prevent the loss of water around the nozzle. By using a double-flow catheter and compressing the outflow tube at intervals the colon may be flushed with sterile water or salt solution, after which such medicated solutions as may be preferred may be run in and allowed to remain. This thorough flushing of the colon should not be done more than two or three times a week at first and later not more often than once a week. In case there is much blood in the discharge a solution of silver nitrate seems to do more good than any other remedy. It should not be stronger than one-half of one per cent at first, and may be gradually brought up to two or three per cent. It should not be used more ofter than once a week, and if it causes much pain it may be followed by the normal salt solution, but this should never precede the silver. In case amebic dysentery is present the solutions used should be cold, as the ameba can not live in a low temperature. Tuttle claims to have cured several cases with ice water. A line of treatment which consists mainly in giving large doses of epsom salts has proven very successful, mainly by keeping the colon clear of irritating material. This constant cathartic action of the drug is very depressing to the general health and really accomplishes no more than irrigation with salt solution. Great care should be taken with the diet and only the most easily digested, nutritious food given. Tea, coffee, and all alcoholic drinks should be prohibited. The treatment in the chronic form of the disease is necessarily slow and tedious, and requires considerable time, but if carried out faithfully will generally result in a cure. Should it be found impossible to bring about a cure by the methods outlined, a colostomy may be done and, by diverting the fecal current, give the bowel complete rest, or an opening may be made in, the cecum and by means of a catheter the treatment may be carried on, both from above and below, as recommended by Gib son. 500 Brown Block. [Written for the MEDICAL BRIEF.] Pneumonia. BY IRA W. UPSHAW, M. D., Professor of Physical Diagnosis in the American Medical College. St. Louis, Mo. Pneumonia in this latitude is one of our most common diseases and at present very fatal under some lines of treatment; therefore, it is necessary that one should be able to diagnose it in the early stages and abort the same. Usually we see our cases pass from simple attacks of congestion to cases of true pneumonia while we wait for the bacteriologist to find Frænkel's diplococcus. This accounts for the high death rate which some physicians report. On being called to a case of pneumonia we get first a history of undue exposure, followed by chills, either slight and indefinite or severe, according to the severity of the case. Following this we have a rise in temperature, rapid respiration, increased pulse rate, followed by feelings of oppression in the chest, with pain on each inspiration, and often a "grunt" with each expiration. Restlessness, fear of some impending danger, flushed cheeks, especially flushing of the cheek corresponding to the lung involved. Dilatation of the nostrils; both sides of the chest usually move alike, but in the later stages the affected side may show decreased movement, the unaffected showing increased movement to compensate. By percussion we find increased dullness over the affected area, except in the very earliest stages of the disease we may get a tympanitic note with slight or no dullness. By auscultation we find a feeble or suppressed breathing over the affected area and crepitant râles at the end of the inspiration. If some of the smaller bronchi are blocked, which may occur, we have absent or feeble respiratory sounds. These symptoms, in connection with cough, rusty sputum (not present in first stage), pain in affected area, difficult breathing, is sufficient for our diagnosis. In treating pneumonia we can have no set line of treatment, each case being different. First, move the bowels thoroughly, preferably with mild chloride or citrate of magnesia, following with the usual sedatives, aconite for the small pulse; veratrum for the full, bounding pulse; bryonia when the cough is short, sharp and dry; ipecac when the cough is dry, showing lack of secretion; asclepias when the pleura is involved and pain is increased on inspiration. Jaborandi may be used where we wish the diaphoretic action, but I usually depend upon the asclepias; ammonium chloride when the sputum is sticky and ropy, causing it to hang in the throat and tax the patient's strength to expectorate; cactus when the heart is weak. Other remedies may be indicated, such as sodium sulphite, baptisia, echafolta, digitalis, codein, etc. The diet should be liquid and as nourishing as possible. After the temperature returns to the normal and the skin is moist, with a clean or cleaning tongue, give one- or two-grain doses of quinine every three or four hours. Locally apply lard and turpentine hot every three hours, wrapping the entire chest in cotton or, better still, covering the entire chest with some one of the glycerine preparations, and then wrapping in cotton. Renew same every six to eight hours, according to the severity of the case. If there is a catarrhal condition of the air passages and the patient does not recover promptly, put him on some preparation of creosote. If this line of treatment is followed out with proper attention to the care of the chest there need be little fear of pneumonia. 5015 Shaw Avenue. [Written for the MEDICAL BRIEF.] Some Indications for Brain Operations. BY ALBERT E. STERNE, A. M., M. D., Clinical Professor of Nervous and Mental Dis eases Indiana Medical College, Purdue University School of Medicine; Consulting and Visiting Neurologist to the City Institutions; Medical Director of Norways Sanatorium, etc., Indianapolis, Ind. So frequently is the question asked of the writer, "what cases are suitable for brain operations, and what are the results of operative interference upon the skull and its contents," that he is impelled to write a few words upon the subject. First of all, it would be wise to differentiate between operations of "necessity" and operations of "choice." Under the caption "Operations of Necessity" would essentially fall the conditions arising immediately after injury to the head, and those which we might consider as surgical efforts to relieve any immediate danger to the life of the individual. The question as to whether operation is necessary and to what extent the surgical procedure should be carried to relieve the immediate effects of traumatism, depends very largely upon the nature of the injury to the skull and brain. Again, we should differentiate between injuries of impact and injuries of momentum. Injuries of impact are those occasioned by the use of a hard object which comes in contact with the skull in a circumscribed area. Such injuries, as a rule, consist of a tearing or cutting of the scalp, and injury to the bone beneath, with or without fracture of both the inner and outer table of the skull at the site of impact. Under such circumstances it is always advisable to enlarge the opening in the scalp to an extent sufficient to determine whether there has been a fracture of the bone beneath. In the event of such frac ture radical removal of all fracture particles, of spiculæ penetrating into the brain tissue, is absolutely essential. If this be done the victims of accidents of this character usually recover; provided, of course, the trauma has not been of such degree and extent as to create very serious damage to the brain tissue itself, or unless one of the large sinuses be torn. Injuries of momentum, on the other hand, are of a different character. These are occasioned by the impact against the head, either of a heavy, soft object, wielded with force, or by the weight of the body itself, which acts as a source of momentum. In a traumatism such as this there may not even be a laceration of the scalp, although this is likely to occur in addition to extensive bruising of the surrounding area. There may be, and frequently is, fracture of the cranium at the site of the blow, very frequently only the inner table being broken. Ordinarily, immediately beneath the skull at the point of injury there occurs hemorrhage of greater or less degree, but not infrequently the hemorrhage occurs at a point opposite the site of the blow, by counter shock (contre-coup). The immediate effects of momentum injuries are apt to be profound, and partake of the nature of what is called brain concussion, or better said, brain commotion. The symptoms may be very profound, extending to complete coma shortly after the injury, unless operative measures are rapidly set into play. As a matter of course, it is necessary that thorough knowledge of focal symptomatology be the possession of the physician and operator in order to determine the exact location upon the cranium at which trephining should be done. It would take us too far in a paper of this length to detail all the various focal symptoms that might arise in cases of momentum injury, but, as a rule, it might be considered a safe counsel to advise the first entrance into the skull at or near the site of injury. If there should prove to be no lesion beneath the skull at this point, it should be the rule to open a second time at a point approximately opposite the site of the traumatism. Not unusually we find extensive hemorrhage in injuries of this kind, sometimes extra-dural, sometimes beneath the dura, and very often in addition we find severe lacerations of the brain tissue itself, with additional hemorrhage from the torn blood vessels lying within the brain tis sue. Injuries of momentum are not only to be looked upon as extremely serious at or shortly after the time of occurrence, but of profound prognostic significance as to the future life of the victim. Not uncommonly we see patients who develop serious intracranial lesions remotely, sometimes years after the injury has been received. Such lesions are prone to consist of cysts and abscesses, and there may be, in addition to these or without them, lesions of a finer character affecting the cellular life of the brain, and upon which there develops a higher or less degree of true dementia. It will be seen, therefore, that injuries of this character achieve a very considerable dignity and should invariably be looked upon with serious eye and consideration. One point is worthy of special mention in momentum injuries, viz., that a rapid recovery from the immediate effects of the injury which is quickly succeeded by recurring symptoms of profound brain pressure, is an invariable indication for operative interferences, as it usually indicates renewed and excessive hemorrhage. Persons who have suffered at some previous time from momentum injuries form one category of those who go to the neurologist and surgeon for operations which should be looked upon as those of choice or selection. They represent a very considerable proportion of cases suitable for operation. Probably the major part of brain operations is undertaken for the relief of epilepsy arising remotely after injuries, and the prognosis, not only of the operation itself, but of the |