The specific

ceive the water. It is a good plan to have two buckets small quantity of fat only was found. set aside for kitchen slops, one for liquid and for solid gravity was light and the amount of albumen large. refuge. If a perforated basin is placed on the one, the Cultures made from the fluid remained sterile, and it liquid can be readily separated from the solid. This method of waste water disposal, if used with care, I know to be practically very efficient.

was not altered by filtration. No clotting or separation into distinct layers took place on standing. Such cases are rare; previous recorded instances are those of Lion, Achard, and Sainton.

Professor Poore has recommended another kind of surface drain, constructed of perforated bricks arranged The patient was a man, aged 43, who died from the over a suitably prepared trench. This is highly praised effects of chronic peritonitis and cardiac failure. Par. by some English physicians, and if properly constructed acentesis abdominis was performed twenty times, the would likely give entire satisfaction. In certain places fluid being clear; the twenty-first tapping was remarkasubsoil irrigation might be the only method available, ble in that the fluid had the milky non-chylous characand if well made with agricultural drain tiles would ter. Frequent tappings after this date showed the same probably answer all the requirements of a good drain. appearances. Blood taken from the median cephalic Solid kitchen waste can either be buried, or, if soil is vein clotted naturally, and the serum was quite translu available, be placed on the corner of the garden bed, ent, and at the post-mortem examination the right pleu covered with earth from time to time, and allowed to ra and the pericardium contained clear effusions, so that nitrify. Another way of disposal is by the fire of the there must have been some local factor at work; but kitchen range, or a specially constructed furnace. post-mortem no pressure on the thoracic duct could be made out, and there was no cancer in the peritoneal cavity, so the milky color could not, as in the previously recorded cases, be explained by the degeneration of cancer cells taking place in the ascitic fluid. The cause of this condition is not clear, but there are apparently two kinds: (1) in which the blood serum generally is milky, as in Achard's case; and (2) as in which the condition is quite a local one, as in Sainton's case and the author's.

For the reception of broken crockery, tin cans, etc., nothing serves so well as a flour sack. When necessary to empty it, it may be tied, carried away, and the contents used for filling. Sewage disposal sometimes forms an item in rural hygiene. It has been customary for isolated houses to dispose of their sewage into a cesspool. Instead of a cesspool a shallow tank should be constructed, and the contents disposed by irrigation over a neighboring field. This is the scientific way to dis pose of sewage.

The proper construction of dwellings may be consid ered a third chapter in rural hygiene, for nowhere else are the houses so badly constructed. The foundations and cellars are almost always damp, and the large amount of phthisis, muscular rheumatism and catarrhal inflam mations in the rural districts otherwise healthy is ample proof of the factor of dampness. Heating and ventilation are both very crude.

School hygiene, which deserves a separate chapter, is beginning to make a little progress, yet the floor and air spaces are usually much too low and the lighting is always defective. Heating and ventilation are especially bad. I doubt if there is one country school in Pennsylvania where these points are anything like the sanitary requirements. Even when hot air furnaces are used, the misplaced outlets carry off the warm air before it has circulated around the room. A common stove, such as is used in most country schools, can be made into a very effective heating apparatus by properly construct ing it into a "ventilating stove," and having the foul air outlets suitably placed. The old idea that the warm air inlet should be at the lowest part of the room and the foul air outlet at the highest point are well-known fal lacies.

Milky White Non-Chylous Ascites.-Apert (Bull. de la Soc. Anat.; Brit. Med. Jour.) gives an account of a case in which the acitic fluid exactly resem bled chylous ascites to the naked eye, but microscopically did not contain fat globules, and chemically a very

g.

Fatal Polyneuritis.—Brauer (Berl. Klin. Woch.; Brit. Med. Jour.) discusses a case occuring in a syphi litic patient treated with mercury. A man, aged 24, acquired syphilis in the beginning of August, 1895, and was treated with a five weeks' course of mercurial inunction shortly afterwards. At first 3 g., and later 5 were used daily. There was no stomatitis or salivation. Toward the end of five weeks he experienced a feeling of numbness in the fingers, and the arms became weak, but the legs were unaffected. The mercury was at once stopped, but as he was going home he experienced some uncertainity in his gait. On the second day the legs became weak, and on the third day there was some difficulty in speech; swallowing was also difficult. He became speedily worse, and on October 9, secondary syph. ilitic skin affection appeared. For this he was treated by injections of salicylate of mercury. The syphilide disappeared, but the nervous symptoms became worse. when admitted into the medical wards there was a wellmarked paresis of both arms and legs. No muscles were completely paralyzed; the movements were ataxic; there was impairment of sensation, but no pain; the pa(tellar reflexes had gone. Coarse fibrillary twitchings were present in the affected muscles; the nerves were tender, and in a less degree the muscles; there was a partial reaction of degeneration; the sphincters were easily disturbed, and there was moderate constipation. Suffocative attacks supervened, and the diaphragm was found paralyzed on January 10. Death resulted from pheumonia. Marked pathological changes were found

in the nerves, consisting of degeneration in the medu- and contracted pupils; and again, it is usually the case lary sheath, and a slight proliferation in the instertitial that in hemorrhage into the brain symtemic shock is tissue. The axis cylinders were slightly swollen in more manifest. It is true, on the other hand, that places. There was no disease in the nerve roots, and thrombosis of the cerebral blood vessels is rather a conno pathological changes in the minute arteries. The dition of advanced age than of youth, and it is a note. brain and spinal cord were intact. The muscles only worthy fact that thrombosis frequently comes on during showed slight morbid changes. There was no other sleep, whereas hemorrhage usually follows some exerpossible cause of the neuritis than recent syphilis tion and frequently takes place after the ingestion of and mercurial intoxication. In syphilis the nervous circulatory stimulants. The history of syphilitic infec system may be involved, either by the specific syphilitic tion producing an endarteritis would, of course point to lesion or by changes caused by the toxins in the blood. thrombosis quite as much as to hemorrhage. a true syphilitic affection could be excluded with certainty. The slight changes in the interstitial tissue in the nerves were in all probability due to degeneration in the parenchymatous elements. Syphilitic neuritis ulcerative endocarditis or their results, or other causes does not occur in so widespread and symmetrical a form. Finally, syphilitic nervous affections rarely supervene at a time when syphilitic manifestations are disappearing under antisyphilitic treatment.

The differential diagnosis of paralysis due to embo lism from that due to hemorrhage is still more difficult, but should the physician find evidence of chronic or

for the formation of emboli, the diagnosis would be rather in favor of such a cause than of hemorrhage. It is also a noteworthy fact that paralysis from embolus is more commonly met with on the right side of the body owing to the fact that it is more easy for the embolus to pass into the left middle cerebral artery than into the right. If it is embolism or thrombosis it will, as a gen. eral rule, be a mistake to bleed the patient; while if the cause of the paralysis be hemorrhage, venesection is usually indicated.

brain substance through the leaking blood vessels; and at the same time the depletion results in a fall of general blood pressure so that hemorrhage ceases by the more rapid coagulation of the blood and the plugging of the artery, and death is put aside because the opening in the skull prevents the compression of the medulla, which Hill's experiments have proven to be so fatal.

The Treatment of Apoplexy. There are few conditions (Ther. Gaz.) met by the practitioners of medicine in which the possibilities of treatment are so limited as they are in that condition which we generally term apoplexy, for although this term has been applied to a general train of symptoms, these symptoms may Hill even goes further than this, and asserts his belief arise from several different causes, and, unfortunately, that in cases of paralysis due to hemorrhage it would each and all of these causes have heretofore at least been be a justifiable experiment to open the skull-cap in order largely beyond medical or surgical treatment. Within to relieve the pressure which is being exerted upon the the last year there has been published in the shape of a small volume an exceedingly valuable experimental research by Leonard Hill, of London, upon the physiolo gy and pathology of the cerebral circulation; and in its pages, in addition to finding much of great interest, certain thoughts are advanced which may be of value to the physician in the treatment of the conditions of which we are speaking. Hill emphasizes the fact that depletion is only indicated when the arterial tention is high, and he reiterates the statement already made by Gowers that before depletion is attempted the diagnosis of hemorrhage should be reasonably certain, because in thrombosis, embolism and acute cerebral anemia a loss of blood will only do harm by weakening the cerebral circulation. The question as to the differential diagno sis between the paralysis produced by hemorrhage, by thrombosis, and by embolism gain an additional impor tance from a therapeutic standpoint over and above its diagnostic interests.

Hill also emphasizes a fact which has been familiar to physicians for many years, but which has not heretofore rested upon such scientific evidence, that free purgation depletes the brain and causes a determination of blood to the abdomen; and, on the other hand, that the application of cold to the head fails to cause constriction of the cerebral or any other vessels.

Chronic Diphtheria. - Chronic diphtheria is rare. Mackenzie has cited a case in which the membrane persisted in reforming for three months. Other cases are reported by Isambert, Barthez, and Heybre. (See "Reference Handbook of the Medical Sciences," Vol. II, p. 470).

Apoplexy, which is due to hemorrhage in the brain, is usually met with only in that class of patients who have attained such an age that their arterial walls are The following case, reported in detail, can not thereundergoing atheromatous changes, although of course fore but prove of interest. A. H. L., aged 5 years, a the presence of a syphilitic history, or other causes healthy, robust child, though subject to attacks of tonwhich tend to produce such changes in the arteries, may sillar inflammation, was taken with the usual symptoms result in hemorrhagic apoplexy during the earlier years of diphtheria, December 30, 1896. In my first examinsof life. Again, in hemorrhage into the brain consci tion of the child the tonsils were found uniformly swol ousness is generally lost, and the compression of the len and dotted with points of exudation, while the enlower centers in the brain which is produced by hemor tire pharyngeal mucous membrane was the seat of catarrhage is apt to result in the development of vomiting rhal inflammation. The clinical features were those of

acute follicular tonsillitis. There was no evidence of dition of immunization by regular and systematic repe. constitutional involvement.

In view of the fact that the child had been exposed a few days before to possible contagion of diphtheria, he was isolated and his case was carefully watched. He was treated with a mixture of tincture of chloride of iron and glycerin. The throat cleared in three days and the child appeared entirely well. On January 3, 1897, slight hoarseness appeared, which on the follow ing day increased to complete aphonia, with a strong tendency to laryngeal stenosis. I promptly injected two thousand units of antitoxin, and in view of the increasing obstruction to respiration advised early intubation. This was done at night of the same day by Dr. Edwin Rosenthal, of Philadelphia. At the same time the second dose of two thousand units of antitoxin was given. The patient was at once relieved and fell into a restful sleep. He soon began to expectorate large quantities of shreds of membrane, which apparently gave permanent relief. During the three doys follow. ing there was a steady improvement in the constitutional condition.

tition of the dose. In accordance with this plan I ad. ministered antitoxin in five-hundred-unit doses night and morning, and continued for five days, when, there being no further indications for treatment, it was discontinued. There was no relapse and the progress to complete recovery was speedy and entirely uneventful. The prominent features of the case are the persistent teudency to relapse, the relapse always being a new in. fection and the point of infection probably chronic ulcers, and the prompt response of the disease to antitoxin, as shown by the early amelioration of all the symptoms and the disappearance of the membrane. No injurious or untoward effects, either general or local, were noted from the frequent and repeated injections of antitoxin. During the entire period of illness the child received sixteen thousand five hundred units of concentrated antitoxin.

As regards the effect of the administration of the antitoxin upon the temperature of the child, each injection was followed by a slight rise, which soon subsided. During the progress of the disease the temperature was several times found to be subnormal for a few hours' duration, a temperature as low as 95° F. being recorded. There is no doubt that in this case intubation prolonged life till the antitoxin could produce its effects, and that in the selection of antitoxin that product which represents the largest number of immunizing units in the same quantity of serum is to be preferred, since this reduces to a minimum the possible globucidal action upon the blood and the tendency to excite uticaria.-John H. Moore, M.D., in Medical Record.

Stankowski

On January 7, the membrane appeared in the larynx. Two thousand units of antitoxin were injected, followed in several hours by another injection of one thousand units. The tube, which had been replaced, was coughed up, yet withing twelve hours all the symptoms were greatly ameliorated and the patient was apparently on the high road to recovery. Up to the 10th of the month he seemed entirely well, the throat being free from membrane. On the following day, however, he began to be dull and apathic, and a patch of membrane was seen forming upon the soft palate. I promptly injected fifteen hundred units of antitoxin and at night gave an- Acute Edema of the Larynx. other injection of one thousand units. Within twelve (Muench. Med. Woch.) relates two cases due to iodide hours after the first injection of antitoxin there was of potassium: (1) A man, aged 29, was suffering from great improvement. The lassitude had disappeared and pulmonary and laryngeal phthisis. The laryngeal manthe appetite returned. Improvement continued till Jan- ifestations consisted in infiltration of the interarytenoid uary 16, when another relapse occurred, preceded by and right aryteno epiglottic folds. He was treated with the same symptoms as before. This time the membrane potassic iodide with the view of improving the nutri occupied a much more extended surface, involving tion. In five days a considerable edema of the left erynearly the entire pharyngeal mucous membrane and the teno-epiglottic fold was noticed, which disappeared posterior nares. I made a local application of corrosive when the iodide was discontinued. The author gives sublimate, 1 to 5,000 solution, and followed up with his reasons for believing that this edema was due to the systematic application of Loeffler's solution No. 2. Anti-iodide, and was not a manifestation of tuberculosis. (2) toxin was again injected, the dose being one thousand This case occurred in a man, aged 31, who had been units, which was repeated in five hours. Repeated bacteriological tests showed the presence of the bacilli diphtheria, but why they persisted in reasserting them selves and why the antitoxin failed to produce the char acteristic immunity to the disease were the points of special interest.

treated with several courses of mercurial inunction. Some six years after the initial lesion he was given potassic iodide as syphilitic manifestations had again appeared, as well as a solution of iodine in potassic iodide to be applied to a swelling on the lip. After he had been taking the iodide for two weeks he began to During all this time I had used mercury freely, either suffer from coryza and dyspnea. There was an edemain the form of the mild chloride of the bichloride, as tous swelling on the right side of the larynx. The adjunct to the treatment. Noting that some clinical ob iodide was omitted, and the swelling in the larynx soon servers have found reasons to believe that the constitu- disappeared. In this case there was no infiltration, and tional effects of mercury are antagonistic to antitoxin, I the swelling had not the characteristics of a syphilitic determined to discontinue the mercury and depend perichondritis. The edema was unilateral in both cases, wholly upon antitoxin, and, if possible, keep up a con- a feature not often met with in cases hitherto recorded.

In the first case 12 g. of iodide were taken in five days; periods of time. He combines iodide of potassium with and in the second case iodide had previously been taken it in cases of sclerotic cardiac degeneration. The favorwithout any evidence of iodism. In both cases the able action of this combination on the force of the edema did not appear at the commencement of the heart, the excretion of the urine, and the quality of the treatment with small doses of iodine, as has generally been known to be the case. The laryngeal symptoms were never urgent, as has happened in most of the re corded cases.-British Medical Journal.

pulse has been obvious. The good effect is produced where there is no evidence of syphilis. In case of the degenerate and fatty heart with only slight arterio-sclerosis the iodide may be not only useless but even harmful. Neumann uses the infusion of digitalis with the iodide. He has not had the same good results with strophanthus as with digitalis until recently, when he

The Increase of Insanity.-To the careful and conservative student of lunacy in the United States it becomes more and more apparent that there obtains obtained a French preparation of strophanthus in the from year to year a constant and alarming increase in shape of a pill. It is merely a loss of time to use other the number of lunatics and feeble minded people in this remedies, including caffeine. When the severer symp. country (Dietetic and Hygienic Gazette) Whether from toms are relieved, nitroglycerine may be useful. Suitaheredity or vicious practices, this fact remains indispu. ble iron preparations may be given when the condition table. From 1870 to 1890 the number has grown in of the patient has improved and the stomach will stand proportion to the population over one hundred per them. The effervescing citrate of iron and ferratin are cent. It does seem for the social welfare that some the best; the latter may be taken in milk or broth. Ferradical means should be at once adopted to relieve this ruginons waters may be employed in place of these condition, and it is greatly to be feared that the present preparations. system of treating lunacy is at fault or this increase would not be in evidence. Too little stress has been placed upon the importance of detecting and treat ing insanity in its earlier stages and of seeking out and providing against heredity transmission. The system of treatment and discharge prevailing in asylums has associated with it many evils. The patient is admitted and treated for the ailment and then discharged, cured to all outward appearances, but really retaining in his

system the seed of the disease, which is more than often

communicated to his children. It is indeed fair to suppose that the army of 12,000, which is discharged yearly from our asylums, propogate their species with considerable activity and direful results. Heredity is probably the parent of all disease and a revision of our marriage laws to the end that a person of unsound mind should not be allowed to marry, would probably bring about much happier consequences.

a

Toxic Diphtheria, Hemorrhagic Form, Death.-Ghika (Jour. de Clin et de Therap. Infantiles) Trousseau Hospital in very bad condition, after an illreports the case of a girl, aged 5 years, who entered the ness of eight days. Swelling of the neck was very marked, especially on the right side, where the skin was reddened, and a hard, indolent edema present. The en

tire throat seemed filled with false membranes, beneath There was great prostration, which increased in spite of which the pharyngeal wall was intensely reddened. serum injections. Two days later there developed hemorrhages from the mouth and nose, and pulmonary inbefore death. The temperature was not elevated during farctions. Complete anuria persisted twenty-four hours the three days of observation.

At the autopsy the multiplicity of visceral hemor rhages was very striking. The pharyngeal walls and while the lungs showed large infarctions and extensive surrounding cellular tissue were infiltrated with blood, hemorrhages; there were sub pericardial and endocardial ecchymoses. All lymph nodes were large, many infiltrated with blood. Congenital hydro nephrosis existed on the right side, with diffuse nephritis of the left kidney. It is very rare, indeed, to find such generalized hemorrhagic effusions during life.-Archives of Pediatrics.

The Treatment of Chronic Cardiac Insuf ficiency.-F. Neumann (Berl. Klin. Woch.) begins study of this subject. The cases referred to, says the British Medical Journal, include uncompensated valvu lar disease, cardiac hypertrophy due to renal disease, chronic myocarditis accompanying arterio-sclerosis, etc. The author speaks of cases in which the disease had lasted twenty, thirty, or forty years. Experience has convinced him that people with cardiac disease, by adopting a simple and regular mode of life, may live for a long time without any limitation of their activity or of a moderate enjoyment of life. It is when the heart muscle becomes affected that the circulatory difficulties become obvious. In general the author finds that the patients just living within the limit of their cardiac power are pale and thin and show no evidence of Having had occasion to observe cases of typhoid fever plethora. Oertel's treatment is certainly not applicable in children under five years of age, at which time, all to some cases. Digitalis remains the most important authors agree, the disease presents an appearance which remedy. The author uses it in large doses over short is often peculiar, the author feels justified in adding his

Some Clinical Peculiarites of Typhoid Fever in Very Young Children.—In the Ann. de la Policlin. de Bordeaux for March, there is a long and comprehensive article on this subject, by Dr. Rocaz, of which the following is the substance:

observations to those already published, and in drawing ceptional and always slight, and sudden death has been the following conclusions:

The onset of typhoid fever in young children is more frequently sudden than in adults, and its appearance is often marked by a sudden elevation of temperature, the thermometer rising in a few hours from normal to 104° and more. Pillet and Barthez think this sudden onset indicate an altogether peculiar gravity of the disease.

observed only two or three times.

Thoracic symptoms are in the normal form less marked than in adults, although broncho-pneumonia is a very grave complication in abdominal typhus in children under five years of age.

Lenticular rose colored spots are the only pathogno monic symptom of typhoid fever in young children; they present no peculiar characteristice either in their frequency, their time of appearance, or their prognostic importance. Epistaxis is considered by the author as being altogether exceptional in young children. Sudam· ina are frequently observed, and they generally appear shortly after the red spots. Livid streaks near the ar

cy, and they are due to an increased growth which is sometimes surprisingly rapid. The frequency of desqamation is also a peculiarity of infancy.

With regard to the possible complications of typhoid fever in young children, the author mentions those of the nervous system, which, he says, are seldom observed in children under five years of age.

The intestinal symptoms are generally less marked in children than in adults. There is a rather exact relation between the number and extent of the ulcerations on the one hand and the age of the patients on the other. The younger the children the fewer and smaller the ulcera tions. Constipation is the rule during the early days of the disease; it is obstinate and does not yield sometimes ticulations, particularly the knees, are peculiar to infanuntil after the administration of several purgatives. When it does not continue during the course of the dis ease, it is replaced by a slight diarrhea which presents nothing characteristic. Hence it may be readily under stood that intestinal perforation and hemorrhage are ex cessively rare in very young children. Enteritis, on the contrary, is a more frequent complication in children, and it is characterized by the persistence of the diarrhea. after defervescence; this diarrhea is rebellious and some times requires an energetic treatment and a strict diet. Vomiting is frequent enough in children to be regarded as a part of the regular train of symptoms of the dis ease. Lack of appetite in young children is so pro nounced as to become almost a veritable danger. Mous sous has cited two cases in which the children refused everything, except a few mouthfuls of pure water, for twelve days.

With regard to the appearance of the tongue, the au thor states that in many cases observed by him in very young children, in which the temperature rose to 102 6 and 104 5°F., the tongue remained moist.

The temperature is very nearly like that observed in adults, although it often assumes a less regular progress in children. This irregularity has led to much discuss ion in regard to its prognostic value. The only fact that seems to the author worthy of mention, concerning the temperature in young children, is the very frequent occurrence of hyperthemia and the facility with which it is borne by the patient.

Other complications, such as arthritis, otitis, thrush, torticollis, stomatitis and phlegmasia alba dolens, are also frequent in very young children. Abnormal erup tions are more frequent in children than in adults.

The duration of the fever is shorter in infancy. According to some authors, relapses occur more frequently, but they are usually less serious than the first attack.

Convalescence is, therefore, rather rapid, and the child recovers with a rapidity that is sometimes aston ishing. The aphasia of convalescence, which is very frequent in children, is nearly always curable.

The prognosis of typhoid fever in young children is dependent upon their age. It is very grave in children under three years of age, not so serious at four years, and nearly always favorable at five years and over.--N. Y. Medical Journal.

Pulsus Paradoxus on One Side.-Gerhardt (Berl klin. Woch.; Brit. Med. Jour), in reference to the case of a woman who had fewer beats in the left radial than in the right one (the right radial pulse corresponded to the heart beats), reported the case of anDicrotism of the pulse has never been observed in very other patient in whom exactly the same phenomenon young children. During the height of the disease the was observed. At the post mortem examination, fresh pulse is generally regular, ranging from 110 to 140 pul- purulent pleurisy and pericarditis were found, and the sations a minute During defervescence and convales subclavian artery when slit open on the right side meascence, however, it may present a peculiar characteristic, ured 2 cm, whilst that on the left side measured only which has been fully dwelt upon by de Gassicourt and 0.8 cm. Gerhardt thinks that the pericarditis caused Revillot, who occasionally saw the pulse become slower the pulsus paradoxus, whilst the stenosis of the left and present irregularities which caused it to resemble subclavian artery caused some of the cardiac pulsations the pulse in certain stages of meningitis. This peculi not to be felt in the left radial. By experiments on arity, which lasted from 8 to 15 days, did not seem to healthy persons, it was found that if a certain degree of have any unfavorable significance. The irregularity of continuous pressure be exerted on the artery of one the pulse in the febrile period is more serious, for it in arm, the pulse can not be felt at the corresponding dicates then a cardiac exhaustion which often presages wrist during very deep inspiration, though during ordideath. The heart, however, is rarely seriously involved nary respiration the pulse continues to be felt at both in typhoid fever in young children; myocarditis is ex- wrists.