almost the universal choice of all the States of the Union. Two or three favorite sons, as it were, were presented by different States, but withdrawn before the final vote was taken, and the rare honor fell to Dr. Joseph M. Mathews, of Louisville, Kentucky, of being elected President of the American Medical Association unanimously on the first ballot, receiving the vote of every State in the Union. Indeed, the Secretary of the Nominating Committee was empowered to cast the ballot for Dr. Mathews. Such a high honor, presented in so beautiful a way, rarely falls to the lot of man.

Book Reviews.

The following monographs have been received since last issue:

NEW FORCEPS FOR INTESTINAL ANASTOMOSIS. By Earnest Laplace, M. D., LL. D., of Philadelphia.

CHOLELITHIASIS, WITH REPORT OF CASES. -By A. Morgan Cartledge, M. D., of Louisville.

NEUROTIC ECZEMA. — By L. Duncan Bulkley, A. M., M. D.

THE SURGERY OF THE GALL-BLADDER AND ITS DUCTS.-By H. O. Walker, M. D.

FURTHER CLINICAL OBSERVATIONS ON THE USE OF THE VALERIANATE OF GUAIACOL GESOT.-By Dr. Riech, Bassun, Ger.

SUDDEN DEATH AND THE CORONER.-By John H. Huber, A. M., M. D., New York.

ON THE INDICATIONS FOR THE METHOD OF WASHING OUT THE PUERPERAL UTERUS.-By J. W. Wills, M. D.

Two INTERESTING CASES OF INTESTINAL RESECTIONS WITH END TO END ANASTOMOSIS BY MEANS OF THE MURPHY BUTTON, WITH RECOVERY.--By X. O. Werder, M. D., Pittsburgh.

TONIC AND SPASMODIC INTESTINAL CONTRACTIONS WITH REPORT OF CASES.-X. O. Werder, M. D., Pittsburgh.

Atlas and Abstract of Diseases of the Larynx.

By Dr. L. Greenwald, of Munich. Edited by Dr. Chas. P. Grayson, Lecturer on Laryngology, etc., University of Pennsylvania. With one hundred and seven colored figures and forty-four plates. Philadelphia: W. B. Saunders.

The colored figures are drawn from life, portraying with remarkable accuracy and vividness a large and varied series of pathological lesions, covering almost the entire field of laryngology. The value of the cuts is much enhanced by being accompanied by a short but complete clinical history of each case. The theoretical portion, while greatly condensed, covers the field with a systematic thoroughness that would do credit to more elaborate text-books. This volume will be especially valuable to students and physicians who are unable to take long courses of clinical instructions in medical centers, who while seeing but few laryngeal cases are desirous of being able to recognize and interpret those that come under their observation.

Examination in Surgery.

T. C. E.

The following was the examination in Surgery at the Denver Medical College, in May, 1898, and we are told that all of the students in the graduating class passed it very creditably:

2.

1. Describe in detail the etiology and mode of growth of sarcomata, and tell how they differ from carcinomata. Give full directions for the treatment of acute gonorrhea. 3. Describe a femoral hernia, give its relations and coverings in detail, and give varieties of inguinal hernia, describing each. 4. Describe the operation of gastrostomy as done for cancer of the esophagus. 5. Describe Stephen Smith's amputation at the knee. 6. Give details in full of removal of a tumor of the spinal cord in the upper dorsal region. 7. Describe briefly, excision of the elbow joint. How would you make a diagnosis between fracture of the humerus below the head and dislocation forward at the shoulder? 9. Define Pott's fracture and give treatment. 10. Diagnosis of extracapsular fracture of the neck of the

8.

The following remarks and observations are for the purpose of giving an illustration of a most effectual method of treatment in septic puerperal complications. At the same time they may serve to suggest conservatism with regard to hysterectomy as a last resort in apparently the same pathological conditions. A communication on the subject from the pen of Dr. Hiram N. Vineberg, in the New York Medical Journal for April 2d, impressed on my mind the importance of advocating uterine irrigations. From the doctor's report of eight successful cases of hysterectomy for acute puerperal septic metritis we infer that success has followed in every intervention; still it may be possible that he meant to speak of successful instances only-otherwise more than eight cases which have been the reverse of successful might have been found, even in the note-books of those operators he mentions, and all this without bearing in mind the deplorable result of a woman losing her sex.

The removal of the appendix or of the fallopian pus tubes seems to be at present the best and most conservative surgery. It is not so clear that infected mastoid cells must also be removed. Here the surgeon feels content with opening the apophysis in order to be

able to wash out most successfully the deadly micro-organisms. The accoucheur, while dealing with the same enemy, might also be gratified with the same brilliant result if he only followed the same line of treatment. Open and wash out well and you will not have to amputate. Every text-book, every professor of surgery, is now preaching the necessity of drainage. It is for drainage purposes that the abdomen, the chest, and the head are opened. To drain and wash what? The mischievous streptococcus, staphylococcus, and their dreadful associates. My custom has been for years past to wash out the uterus, and to keep washing it out, at the first rise of temperature. It being unnecessary to call attention to what a serious puerperal trouble sepsis is in ninety-eight per cent of cases, I will simply remark that the uterine cavity. is an extremely favorable ground for the development of septic pathogenic germs. It appears to be a perfect culture medium not disposed to drain. The os, naturally contracting, will as well as the sphincter vaginæ become a partly closed barrier to the rapid exclusion of pathogenic bacteria. Scrape and wash out and drain and kill by means of antiseptics. "Remove with the sharp curette as much grayish-white fragments of tissues" as you might, it does not matter how much. What we must do is to keep on removing the same continually forming noxious substances. Dr. Vineberg's case conclusively shows that this can not be done with the sharp or any other curette. Taking for granted that septicemia is due to a retained piece of placental tissue, the curette, it is useless to say, must be resorted to, preferring the dull one, sure that it will accomplish the same result, and, unlike the sharp curette, it will not reopen a partly obturated surface or produce laceration in the midst of sepsis. The continued irrigation is to complete the curette's work, and cases that it will not cure will not be saved through hysterectomy.

I now come to my own striking observations, taking the notes verbatim from my note-book. First case, dating back in 1885:

Mrs. M., the wife of a well-to-do

merchant of Duluth, Minnesota, aged twenty-eight years, the very picture of health, gave birth to her third female child; its weight was about nine pounds. and a half; labor lasted six hours, and was in every respect a normal one. The expulsion of the placenta was complete and followed within half an hour. The fourchette was torn, but the perineum remained intact. Every thing Every thing normal at the end of the second day. Patient was not seen on the third day. Or the fourth, at 4 P. M., she was suffering with cephalalgia; had a chill; pulse, 126, temperature, 103.5° F. Ordered vaginal douche, I to 6,000 corrosive sublimate, every three or four hours. On the fifth, at 9 A. M., the same conditic. At 4 P. M. symptoms aggravated; puise, 135; temperature, 104.5°. Had another chill; no fetor, but profuse flakes like muco-pus discharging from the vagina. Ordered uterus to be washed out once in three hours for twenty-four hours. On the sixth, at 5 P. M., no improvement; rigor lasting an hour; pulse very rapid and yielding; profuse sweating; furred tongue; milk fast leaving the breast. Noticing a slight fall of the temperature after each intra-uterine douche, I requested my patient to undergo continued irrigation. On the sixth, at 8 P. M., I began continuous water irrigation for twelve hours, at the rate of seven or eight gallons an hour. On the seventh, at 8 A. M., temperature fell to 100° F.; pulse, 115; felt much relieved. Being then Being then quite sure that I had the case under control, I stopped irrigation. Five hours later patient was seen, and to my horror the temperature had gone up again higher than ever. Half dis couraged myself, I urged the husband. to prompt his wife in submission to the same treatment; they had failed to see all the benefit derived, and reluctantly I was allowed to proceed. On the eighth, at 3 P. M., irrigation was again started and kept up by myself till next day at 12 P. M., when temperature was down to 99.5° F.; pulse, 110. After giving directions to continue for three hours longer I left to take a rest. At 5 o'clock P. M. I returned to find that on the previous day a certain midwife, living in a small town a hundred miles

distant, had been wired for, the said midwife enjoying quite a local reputation among her people. Of course she had taken possession of the fort. "The patient is now in a dry bed and feels much better already. It was an ordinary case, such as is often seen; no one need worry," was her dictum.

I took the husband apart, warned him most earnestly, and left the house. The poor husband was not to blame, for the midwife had been brought in through his brother-in-law (a Swedish minister of the Gospel). I felt sufficiently sure of the result to predict that in twelve hours more the poor mother might be beyond redemption, for the temperature was already rising. On the tenth, at 4 P. M., the discouraged husband came, requesting me to go and see his dying wife, as he said. As he had some knowledge of physiology, and knew something of a normal pulse, in answer to my question how it was, "So fast," said he, "that I can not count it. it." The temperature was now 106.5° F.; pulse about 180; respiration very rapid; abdomen tympanitic and painful; patient delirious. The genital tract was bathed in pus; several chills had occurred. Without losing time a consultation was called with Dr. Walback, a veteran practitioner of consummate ability. Together we decided to resume at once the intra-uterine irrigation.

is unnecessary to say that heart stimulation and careful nursing were used to the best of the best of our ability. For some hours the irrigations did not seem to have the same effect as previously; so, believing that the stream might fail to wash out the whole uterine surface, the ordinary S-like syringe was replaced by a male catheter, No. 12, and the stream was gradually increased from about seven to twelve gallons an hour. Owing to the contraction of the os, the catheter entered with some difficulty into the uterine cavity. After forty hours' work, the temperature came down to 100° F. During these forty hours we suspended irrigation four times, but never for more than an hour at a time; still, these short rests would invariably send up the temperature from a half to a whole degree. At I P. M. on the twelfth, rest till 4 P. M.; the tempera

ture rose from normal to 101° F.; a slight chill. Irrigator resumed, and kept up for three days longer, with intermissions never lasting more than three hours.

Would not this most severe case, full of instruction, be nowadays considered a very strong suggestion in favor of hysterectomy? At first the temperature would not decrease unless the irrigations were continued at the rate of seven gallons of water an hour; afterward the amount had to be increased to twelve. If less water was flowing, if interruption was made, the temperature was sure to rise, sometimes with an astonishing rapidity. It was only on the sixteenth day after the confinement, and after ten days of nearly continued irrigation, that convalescence became permanent. Over two thousand two hundred gallons of boiled water passed through the patient's uterine cavity. As the continuation of antiseptic solution for so long would have been injurious, one pint of a solution of one-and-a-half-per-cent carbolic acid was used to finish irrigation only. Never was there any factor suggesting decomposition in this case. During the first four or five days secretion was very abundant, and apparently composed of flakelike muco-pus; afterward, of yellowish-white pus. On the tenth day, at the time when absorption was greatest, the patient was seized with a violent cough and pain in the right chest; so intense was it that we could not proceed with the irrigation until half a grain of morphine had been given hypodermically, and next day breathing could not be heard, for consolidation was complete. I think this is evidence that the patient could not have stood any further absorption of septic sub

stance.

Dr. Riche and Dr. McComb, as well as Dr. Walback, three of the most prominent physicians in Duluth, Minnesota, having seen the case in friendly consultation, were much pleased with the result arrived at.

Case 2. Mrs. N., confined June 6, 1886, a midwife attending, was seen by me for the first time on the 12th. Temperature, 105°; pulse, 145 to 150, irregular; abdomen painful and tender;

tongue coated. An intra-uterine douche was ordered of a gallon of 1 to 6,000 corrosive-sublimate solution every three hours. On the 13th, at 5 P. M., patient had several chills, was delirious, and very weak. Irrigation ordered for thirty-six hours, stopping four times for an hour. The temperature fell to 100° F. As the patient was adverse to my method of continued irrigation, attempts were made several times to do without them; but three or four hours of suspension always resulted in sending up the temperature two or three degrees. Treatment was kept up for six days, resulting in complete recovery.

Case 3. Mrs. D., confined May 31, 1893, for the sixth time; confinement natural; the os was torn. June 4th, at 5 P. M., the temperature was 103.5°; pulse, 120; cephalalgia. Had several chills. Uterus washed out every two or three hours for six or seven times. On the 5th, at 6 P. M., all symptoms aggravated. Temperature, 104.5° F.; pulse rapid and irregular. Patient felt very weak. I called in a professional nurse and started continued irrigations at 10 P. M., which were suspended three times in thirty hours for an hour at a time. From five to six gallons of water an hour were used first, but, owing to a very slow decrease of temperature, this amount was gradually raised to ten gallons, and kept up till a normal temperature was reached. perature was reached. As previously, intermission for longer than an hour caused the temperature to rise rapidly. The same treatment was kept up for eleven days, with interruption of two or three hours only during the last three or four days. Recovery was complete.

Case 4. Mrs. O. was confined in one of the Montreal hospitals, but on the seventh day was removed to a private boarding-house. On the ninth I was called in. The patient had had several chills, intense cephalalgia, hardly any discharge. Temperature, 104° F.; pulse very rapid, about 140. No milk in the breasts. She was at once removed to Strong's private hospital. Intra-uterine douche, one gallon of warm corrosive-sublimate solution, I to 6,000, once in three hours, was employed, and next morning curettage brought out a quantity of detritus. Intra-uterine

douche of one gallon of corrosive-sublimate solution was used every three hours and kept up for twelve hours, but had not the desired effect. On the twelfth day after the confinement I started continuous irrigations at the rate of eight gallons of boiled water an hour. Eight hours later the temperature decreased from 105° F. to 101° F. -one degree for every two hours' douche. A rest of two hours sent up the temperature to 103° F., abdomen tender, and tympanites quite alarming. Irrigation was resumed continuously for three days, when the temperature

reached normal. Extreme weakness

made it necessary to use ether and digitalis hypodermically. Fifteen days after confinement it was still necessary to irrigate, this being done one or two hours at a time, and at intervals of

every six hours. It was only eighteen days after the child's birth that convalescence became permanent. Recovery was complete.

If it were not for the sake of time and space, I could quote three other cases of the most severe form of septicemia treated with continuous intra-uterine irrigation, with similar success.

In every instance the stream had to be kept flowing until such a time as the uterine cavity had undergone sufficient repair. Only then would improvement become permanent. In every one of the above-mentioned cases recovery was complete. With two exceptions that I lost sight of, all the patients became pregnant again.

Under the influence of continuous irrigation the uterus contracts well and fast. The fissure heals rapidly. Irrigation must be kept up until such time as it is certain that there is no more internal suppuration; otherwise the os, now firmly closed, will retain the discharge, and the temperature will rise again one or two degrees.

All of the above cases were of a most severe character, and left no doubt in my mind that each and every one of them would to the enterprising surgeon of to-day have afforded ample reasons for the removal of the uterus and ap

Administration of Quinine.

Quinine is Seldom Properly Administered. It is not the amount but the way you give it that counts. Give it with an acid if the stomach will stand it, or else in the effervescing form recommended by Burney Yeo.' I quote from him as follows:

"We have found the efficacy of quinine in febrile states very much influenced by its mode of administration. If we prescribe quinine dissolved in citric acid, and given in effervescence by adding it to an alkaline mixture, doses of two or three grains exert a powerful antipyretic influence far greater than that obtained by the same quantity of quinine given in the dry state. We have seen abundant reason to believe that in infective fevers, if quinine be given in saline solutions, it is the most active and reliable antitoxin we at present possess.

A strong decoction of lemon in the early morning is a very useful remedy.

A preparation for giving quinine by the mouth, of particular efficacy in many of the severe varieties, is "Warburg's tincture," and it is a most excellent medicine.

One very strange observation that I have made is worth relating. I had a patient with occasional severe attacks of malaria, who never seemed to get the physiological effects of quinine; in other words, he never had ringing in the

ears.

Thinking that the quinine was not being absorbed properly, although I had given it in various ways, I gave him several hypodermics by the method I shall further on describe, and, failing in this, I put him on big doses of the Warburg's tincture, and, strange to say, one ounce made his ears ring. This extraordinary phenomenon has often been a source of perplexity to me, and, in reasoning about it, I have come to the conclusion that something in this compound may act, in a slight measure, as an antitoxin, or in some way so modify the chemistry of the blood, as well as the activity of the glandular and eliminative system, as to give quinine a chance. It is not true, perhaps, that

1Burney Yeo, Clinical Therapeutics, Vol. II, page 637.