the time of delivery; that the average duration of cases occurring during the first and third periods is six to nine months, in which about 75% recover, 20% improve and 5% die. That cases occurring during the second period average about three to six months, about 40% recover, 50% improve and 10 die. That about 50% of all puerperal insanities develop during the second period and that the average death rate does not exceed 5% of the total population of puerperal insanities.

DISCUSSION, DR. F. E. COULTER.

"I want to commend the efficient way in which the doctor has handled this subject. I heartily agree with him that the present usual way of treating these cases is, as a rule, wrong. This will be very materially changed within the next ten or fifteen years, I think. The class of cases the doctor refers to, as well as others, of the more acute insanities, have all been treated wrong. It is the height of folly to suppose that one superintendent with the few assistants usually found in our state institutions, and most of these assistants untrained, can rightly care for the large number of patients under their charge. Warm baths, as well as life out of doors, etc., have been very effectively used in many instances of acute insanity, but with the limitations in most of our institutions, they are unable to give the proper treatment in these acute maniacal cases. The question of the treatment of insanity is a most important one. We are going to find that many of these cases are on a physical basis and that the cause can be found and can be removed, and when we remove the cause, we are going to cure the disease, just the same as we do any other form of disease. I am glad the doctor has brought this question to the front, as it is important to all of us and the future physician is going to be the one who is going to take careful notice of the mental status of his patient and study these points of the mental state just as he now does the temperature and pulse and other physical conditions of his patient in other diseases."

DISCUSSION, DR. A. B. SOMERS.

L

"I want to speak of a case I had with this trouble. She was a married woman and was at the county hospital. She had three pregnancies and had been insane with every one and recovered after pregnancy was completed. The first two were still-born, but the third was a live baby. It took three or four to hold her during the delivery and she was also partially under an anaesthetic. After her delivery, and when she was in her right mind, I suggested that she have her ovarian tubes removed to prevent a recurrence, but the father was so well pleased with a live baby that 'he refused and I suppose as a result she will again be pregnant and crazy once more."

DISCUSSION CLOSED BY DR. J. M. AIKKIN.

"I will not use valuable time in discussing the different kinds of insanity. I was limited in this symposium to the insanities of pregnancy, but insanity is insanity, regardless of the prefixes or suffixes by which it may be qualified. It is of itself a condition of the mind in which one or more of the mental faculties are weakened, perverted or destroyed. I appreciate very thoroughly the remarks by Dr. Coulter indicating our need of more knowledge for diagnosing and caring for our insane population. I try to impress upon our medical students in the University the necessity of intelligent recognition and treatment of the person or persons whose reason is dethroned. I emphasize the psychic side of how to approach them. The treatment and such other care as would improve their condition we describe as fully as our medical men do in pneumonia, typhoid, nephritis or

any other disease. The treatment of insanity is only one division of the department of medicine and I do not like the idea of too much emphasis on specializing, for we are all co-workers in medicine and should see that our young men who are now going out into the medical profession are equipped with a thorough knowledge of how to treat cases of insanity as intelligently as their other medical or surgical cases.”

Anterior Poliomyelitis-Report of Cases.

*By MARIE A. AMES, M. D., North Platte, Neb.

Writing a comprehensive paper on the subject of poliomyelitis is very much like the Egyptian task of making bricks without straw, as the classical literature of the past is inadequate to the epidemic of the past three years as it has adapted itself to the climatic conditions of the United States. Confronted with a babe or child, with an ailment simulating a half dozen or more diseases embracing everything from entero colitis to spinal meningitis, the task of eliminating is not an easy one to the general practitioner.

The slaughter of the innocents, following the edict of King Herod, was not more devastating than the aftermath of the last great epidemic which swept from Castle Garden across the middle west, until our attention was drawn to the storm center, which settled in Eastern Nebraska, and isolated cases kept a few of us on high tension in Lincoln county.

People do not walk with names of diseases pinned to their backs and the sorting out of certain types differs from the ideal of our student days. Holt, the classic of diseases of childhood, refers to this disease as acute poliomyelitis or atrophic paralysis, with but meager literature on the subject. Loomis, Tyson and Anders are somewhat more elaborate, while we owe our modern neurologists and pathologists what knowledge we have gained up to date. Acute anterior poliomyelitis, acute atrophic paralysis, infantile paralysis is an acute infection involving certain portions of the spinal cord, brain and membranes. The first description of this disease was made in 1774 and has been under careful observation the past half century. Sporadic cases have been reported in all the states during the late summer and early fall months.

Etiology: Modern investigations have conclusively proven that the disease is due to micro-organisms or a combination of micro-organisms, or a resulting toxin or toxins, but they have not been isolated. Lumbar puncture has elucidated some light on the study of spinal fluid, and the dawn is approaching when

*Read before the Lincoln County Medical Society, April 20, 1910.

more material will be given bacteriologists. Sex does not appear to be a causative factor, but two-fifths of all cases occur before the third year is reached. Tuberculosis, syphilis, heredity, teething, chilling, trauma, have all been considered with but negative results.

Pathology: Polio-Encephalo-Meningio-Myelitis is best described in an article in the Western Medical Review, written by Dr. Coulter, of Omaha, and should be kept for future reference. He also divides the course of the disease into four stages: Initial, stationary, regression, lasting six months or more, and finally the chronic stage with resulting deformities, with little or no side lights on treatment. Dr. Langfelt, who is probably the best posted pathologist in the state, and to whom has been given the detailing of the Flexner serum, from the Rockefeller laboratory, in conjunction with Dr. Wilson, of the State Board of Health, make the following statement last fall: The disease made its initial appearance at Stromsburg and the number of cases rapidly increased. The storm center of the disease in Nebraska was in the counties of Polk, Merrick, Hamilton and York, the latter county having the most sensational reports; so much so that commerce was paralyzed and the commercial club had to send out press notices denying that a single case of spinal meningitis had been found in the city of York, but that polio-myelitis had been allowed to spread on account of the disease not having been properly quarantined. Diagnosis in the disease is a serious and important one. Except by inference the diagnosis cannot be made until paralysis appears. In three cases which came under my observation, one was hard to deal with; an ordinary case of entero-colitis, with vomiting, until paralysis made the diagnosis easy.

New York and Chicago boards of health do not require quarantine in these cases, but simply require that they be reported. The Flexner serum has no influence on polio-myelitis and was only used advantageously where the spinal fluid demonstrated meningeal intracellularis and the germ isolated. The presence of toxin in the medulla gave rise to the great mortality. Isolation of cases should be made imperative and quarantine can do no harm, as the evidence points strongly to the fact that infection is in the intestinal tract. We can surely treat that in an intelligent manner.

Case I. Baby Callender, age 16 months, residing at Tryon, had been ill one week with what seemed to be bowel trouble. She was given quantities of blackberry balsam and finally medical assistance called. The case was diagnosed as entero-colitis

and on account of the distance from town and home facilities the child was brought to our home for treatment. Tenesmus was aggravated and from twelve to twenty bowel movements per day of a non-odorous jelly-like substance. Vomiting was constant. We next noticed a dilation of the pupils, vocal paralysis and nystagmus, with rapid emaciation. This condition continued four weeks, until life seemed all but extinct. The atrophy of the muscles was a clinical picture. Treatment was idiopathic and empirical. Acetozone was given in copious draughts of water; massage of the muscles with oil of eucalyptus given twice daily; alcohol baths and finally, when collapse seemed imminent, a spice poultice saturated with brandy was applied to the abdomen. The tenderness of the spine was relieved by frequent paintings of tr. iodine; and fly blister applied to the mastoid process was recommended by Dr. McCabe, with happy results. Dr. Longley recommended Tr. belladonna in 1-10 min. doses for an encroaching encephaloid condition which soon brought the pupils to their normal condition and relieved the bulging fontanelles. The hands never were paralyzed, but the lower limbs continued so for over four months; vocal paralysis lasted over two months; recovery complete.

Case II. Baby Bloomfield was brought to my office in August. History of vomiting and entero-colitis. Gave the usual remedies and left for another case. Child was taken worse and homeopath called, who pronounced it cholera infantum. The acute symptoms quickly subsided, leaving paralysis of the right leg. He was called again and explained that paralysis was reflex caused by an irritation to the clitoras and suggested an operation, but this was refused. The child was referred back to me. Massage was kept up and the paralysis is gradually growing less; in fact, the child is able to walk, but will eventually have to wear a support.

The Preparation for and Operation of Appendicitis and Appendiceal Abscess.

*By W. L. SUCHA, M. D., Orleans, Neb.

Taking up the subject where Dr. Green has left it with cases diagnosed and also a decision to operate, I will treat the two subjects separately in a way and yet jointly, first giving the preparation of each separately, then the technique of operation for each, also separately.

*Read before the Republican Val'ey Medical Society, at McCook, June 30, 1910.

First taking appendicitis This will have to be subdivided into at least two heads, which division I have made for convenience as the acute or inflamed cases and the chronic cases in the resting stage.

Given then a case of appendicitis in the acute or inflamed stage. Do not move but operate in the home. Our process of preparation must necessarily be one of the greatest care, guarding on every turn against any manipulation, therapy or movement that would in any way irritate the appendix or appendiceal region. The extent of this precaution I think can best be determined by the following rule which I have formulated for my own practice: "Handle the patient in such a manner as to not have him complain of the manipulation.'

In these cases I would give enough morphine to induce moderate rest from the time the diagnosis was made until the operation is performed. The average adult patient will require one-fourth grain given hypodemically about every five or six hours, depending upon the size of the patient and the severity of the case. All food having been eliminated upon first diagnosis, nothing need be said of this, as also of the ice bag over the right iliac region. Give no cathartic nor enema unless there is marked distention, in case there is, low enemas repeated every three hours until time for operation. Where tympanites does not occur give no enema. The nearer normal we leave the atient the less meteorism we will have. In these cases tha best technique for preparing the field of operation is simply to shave and sterilize upon the table.

Given a case of appendicitis chronic in form or a so-called interval case, these patients may be taken to the hospital the day before the operation or the nurse sent to the home the day before the day set for the operation. Give a thorough tub bath the evening before and a cathartic if the patient is in the habit of taking a cathartic to secure a bowel movement in the morning. I am in favor of giving the patient precisely the same cathartic they are in the habit of taking, as I said before, the nearer we adhere to the patient's natural ways the more normal our patient will be. In case the patient is normally regular I am opposed to giving any cathartic the evening before the operation. Shave the patient from the umbilicus to the pubes, scrub with gauze and green or synol soap, then with 1-100 bi-chloride solution, then rinse with alcohol (Harrington's solution preferred), and apply a dressing of either 1-5000 bi-chloride solution or 10 per cent synol soap solution (soap .preferable).