nine in complicated and seven in uncomplicated cases. The mortality in the uncomplicated cases under creosotal was therefore 7 per cent., as against 22.8 per cent. in uncomplicated cases under other treatment.

In most of the cases reported in the United States the dose of creosotal rarely if ever exceeded ten minims every two hours. My friend, Dr. W. W. Baldwin, of Rome, Italy, reports to me, however, that he gives as much as thirty or forty minims every three hours, and has treated eighteen consecutive cases without a single death, even when the prevailing type of this disease was fatal. He never saw any disagreeable symptoms from its use. I personally have never ordered more than fifteen minims every two hours, but should not hesitate to do so if that dose did not reduce the temperature within twenty-four hours. I know of no instance in which harmful effects were noted. Smoky urine appears, but is of no moment and negligible.

It is important to begin the treatment at an early stage of the disease, so that the first exudate poured into the air cells. may be impregnated with the drug and rendered an unfavorable culture medium for the germs. When once the cell is packed full with fibrin, the plug will be but little affected by any remedial agent in the blood. But the early institution of the treatment is usually precluded in hospital and consultation practice. In family practice there is a natural hesitancy to use an unfamiliar treatment. Therefore the conditions are seldom favorable for the fullest success of creosotal; nor will this be otherwise so long as the efficiency of any specific is dogmatically denied.

The creosotal has incidentally a decided effect in preventing the formation of gas in the stomach and intestines, with all the discomfort and danger attending abdominal distension.

Should I myself be attacked by pneumonia, I should wish to be treated by a physician who believes in creosotal and will employ it with a liberal hand.

THE NOBEL PRIZE in physical science has been awarded this year to the English physicist, Lord Rayleigh. His co-worker, Sir William Ramsay, received the prize in chemistry. The five prizes now amount to $40.000 each.

Clinical Reports.

CLINICAL SOCIETY OF THE NEW YORK POLYCLINIC MEDICAL SCHOOL AND HOSPITAL.

Stated Meeting, Held January 9, 1905.

THE President, Dr. Daniel S. Dougherty, in the chair.

PATIENT WITH TUBERCULOSIS OF WRIST.

Dr. V. C. Pedersen showed this patient. Several years ago she went to one of the large hospitals of this city, with a condition presenting the early stages of arthritis of the wrist. Expectant treatment was adopted, and was followed by swelling of both the hand and forearm. Notwithstanding the fact that the metacarpal phalangeal joints were ankylosed, no effort was made to reduce the ankylosis by the hospital staff. The patient was then recommended to go to the central part of the State, where she improved in general health. There the supposed diagnosis of tuberculous synovitis of the extensor tendon was made and explored operatively. Six months later she presented herself to the speaker, who did a resection of the wrist. The trapesium and the synovial membrane between it and the thumb were in fairly healthy condition, and were not removed; likewise the membrane between the radius and the ulna, and the pouches between the bases of the fourth inner metacarpal bones. About a year later pain and swelling began to appear on the outer side of the hand, and a secondary operation was performed, when it was found that the trapezium and the synovial membrane were tuberculous. These were removed. The wrist was opened a year after that, and extensive tuberculosis of the metacarpal surfaces of the ulna and radius, and likewise of the other bones, was found, and the third operation was almost as extensive as the original resection. The arm was elongated, allowing the cavity which was left to fill with blood-clot, which organized without suppuration. This was done at the suggestion of Dr. Dawbarn, who was called in as consultant, but personally the

speaker thought it much better to accept shortening, and approximate the bones of the metacarpus to the bones of the forearm. Cosmetically, the condition of the patient's wrist is very satisfactory, and it is hoped that all tuberculous foci have been removed, but it is only five weeks after the operation, and too soon to tell the final result.

Dr. A. Lyle said that for some years it had been his custom to adopt the expectant treatment in cases of tuberculosis of the wrist, but to-day he was in favor of operating at once.

Dr. J. A. Bodine said that in tuberculosis of the hip joint, where it was possible to get more or less perfect rest, there are reasons for adopting the expectant method of treatment; but he thought in the wrist, where the anatomical configurations of the joint are so complex, and where it is so impossible to get physiological rest, it was better to operate at once. He thought the result in the case shown very satisfactory, but it was entirely too soon to judge of the outcome of the operation. PATIENT WITH ARTHRITIS OF KNEE PROBABLY GONORRHEAL.

Dr. Pedersen also presented a patient, the victim of a druggist's error, who, realizing himself to be in the early stages of gonorrhea, entered a drug-store and asked for flexible medicated urethral bougies, stating to the druggist the purpose for which they were intended. Instead of bougies the druggist dispensed pure silver nitrate caustic in sticks, which the patient, in ignorance, inserted with the following results: Excruciating pain and burning, after a few moments followed by total absence of feeling; later tremendous swelling and inflammation of the part appeared; total inability to urinate supervened, so that the use of the catheter was absolutely necessary. The fifth day after the accident there were silver nitrate burns on both thighs, as far as the knees, two or three having penetrated almost or quite through the skin, as subsequent scarring proved. The entire skin sheath of the penis was swollen to several times its normal thickness; the margin of the foreskin was burned raw almost completely around; the glans was violently inflamed, swollen, and edematous. It was impossible to retract the foreskin even partially. The meatus was with difficulty brought into view, and was completely filled with the typical whitish slough of silver nitrate

burn, which extended backward fully four inches, and gave the urethra the feeling of boggy, rotten rubber tubing. Behind the slough the urethra was distinctly tender. The prostate was not investigated.

The urethra was cocainized, a soft lisle thread catheter was inserted into the bladder, and about fourteen ounces of clear urine was withdrawn. The patient was sent to the hospital, and a lead and opium wash applied externally. The copious discharge was found to contain gonococci.

The patient was catheterized once in twelve hours, in order to decrease the likelihood of infecting the bladder. Within twenty-four hours after admission, drainage was carried out through the perineum with the double purpose of stopping the catheterizing and of putting the urethra at rest. At the time of the operation the slough came away in mass, and the urethra and bladder were irrigated thoroughly and copiously with very hot potassium permanganate solution I-4000. Subsequent treatment was irrigation of the bladder with hot potassium permanganate solution and hot boric acid water two or three times a day. The same substances were also used on the urethra. At the time of operation 32 F sound was passed, without force, through the urethra. About six days later, 25 and 27 F straight sounds were passed, with some pain, to the bulb of the urethra. Later, under gas anesthesia, 60 F straight sound was passed. All subsequent examinations of the discharge for gonococci have been negative, and at the present time the patient passes, with the aid of cocainization, 29 F sound quite easily.

On the day following the original operation, the foreskin was slit dorsally from end to end, in order to be sure that there were no severe burns of the glans. Circumcision will be carried out upon the patient within a few weeks. Whether it will be necessary to do an internal urethrotomy through the scar of the deepest burn, in order to gain space, remains to be seen.

HYSTERECTOMY SPECIMEN WITH HISTORY.

Dr. Pedersen also presented a specimen which had been removed from a patient on whom hysterectomy for extensive laceration had been performed. The patient's history, previous

to marriage, was negative. Ten months after marriage she was delivered of a full-term dead child with instruments. Puerperium lasted ten weeks, with severe symptoms. Two miscarriages, the following year, were followed by pregnancy some months later, with what was considered menstrual flow during the first six months. She was delivered of a full-term male child by the breach, with little trouble, puerperium lasting ten days. This child is strong and healthy at the present time. Eighteen months later she was again pregnant, giving birth to a second male child. The mother nearly lost her life through hemorrhage. This boy is also living and in good health at the present time. Nursing was impossible through weakness of the mother; she was, however, able to nurse her first son for fifteen months. In the summer of the following year she was again pregnant, and during the winter nearly had a miscarriage. She gave birth, however, to a female child. This labor was nearly natural, and no physician was on hand at the time. This child is also living and in good health. A year later she was taken sick with apparently accidental hemorrhages during a pregnancy. Upon her physician's advice she went to a hospital in Connecticut, where a curetting was carried out, four days after which she had a miscarriage of apparently a six weeks' foetus.

Later in the same year she again went to the same institution, where she was treated for syphilis. Her doctor, doubting the diagnosis, sent her to a specialist in this city, who positively denied the existence of syphilis in the eruption. In December of the same year the patient had a miscarriage. In December, 1903, she was sent to a New York hospital for the repair of a very extensive laceration, extending almost to the left horn of the uterus. Suture of the tear was done, and secondary hemorrhage almost carried the patient off. After her recovery she was told to return in October for examination, when she was informed that hysterectomy was necessary, but her condition would hardly warrant the operation.

Dr. Pedersen saw her late in October, in excellent general health and spirits, and showing a uterus normal in size, form, and consistency, freely movable from the back, right side, and front, but distinctly adherent on the left, where an extensive infil-,