sure, is so marked that I believe its application, even though in a supplementary manner, is desirable. I do not mean that Apocynum is a cure for spinal meningitis, but that, by diminishing and removing the fluid transuded into the so-called cavities of the cerebro-spinal system, it minimizes those nerve degenerations and clinical symptoms consequent to such pressure. Besides there are variant types of cerebro-spinal meningitis not produced by the meningococcus and not amenable to serum treat

ment.

The action of Apocynum in removing fluid accumulations of a dropsical nature anywhere in the body, is so marked that it has been given the name of the "vegetable trocar." And it occurred to me that possibly this action of apocynum could be turned to good use in relieving excessive fluid accumulations in the cerebro spinal system. For, pathologically, this fluid accumulation is of a nature apparently similar to dropsical effusions found in other parts of the body.

The U. S. P. preparations of Apocynum Cannabinum, commonly called Canadian Hemp, are the tincture and the fluid extract. In practice I have found these preparations excessively irritating and unsuitable for prolonged administration. For this reason recourse was taken to the specific tincture as prepared by Lloyd Bros., of Cincinnati, O. Merrill manufactures a normal tincture. Lloyd's distilled extract may be used if these preparations are unsuitable. Early in the disease I have found the F. E. Ergot to be decidedly synergistic.

Apocynum has an action on the heart and general circulation of a tonic sustaining nature; on the kidneys it acts by producing a large flow of limpid urine; and on the bowels it has a laxative, and in excessive doses, a hydrogogue action.

In spinal meningitis the distinctive symptoms are prostration, toxemia, and the clinical manifestations due to pressure. The use of Apocynum, in the cases I have treated, was immediately followed by the relief of these symptoms. The rigidity of the neck and back diminished, the delirium and the extreme restlessness were relieved, and in a few days the motion of the head was fairly free.

Of course, in the treatment of spinal meningitis there are many factors to be considered for all symptoms must be met and the relief of any one symptom does not constitute the cure of the case. As before mentioned, it is well known that cerebro-spinal fever may be produced by various bacteria. The diplococcus meningitidis causing the epidemic form. Besides the pneumococcus, the grippe germ, the tubercle germ, etc., may be the causative agent. Also there may be mixed infections.

Although not detracting from its practical value, the scientific worth of this paper is minimized by the fact that no puncture was made to determine the exact nature of the infectious agent.

Case No. 1. Mrs. S., age 35, widow, 3 children, the two youngest of which were twins 4 yrs. of age. Patient's personal and family history negative.

Patient came under my observation Mch. 1, '08, when I found her in a condition of collapse, the pulse was small and rapid, the extremities cold, lips cyanotic, neck and spinal muscles stiff and sore. She also had an intense headache. Kernig's sign was present. A macular eruption developed during the first week of the disease and persisted for some time. She also had a very marked herpetic eruption about the mouth.

Stimulation was given in the form of hot applications, particularly to the lower extremities, hot drinks together with the hypodermic injection of atropin. The patient responded but slowly to the treatment. The next day her general condition had somewhat improved, but the rigidity and stiffness in the neck and back had increased in severity. Under treatment the symptoms, with occasional exacerbations, gradually ameliorated so that at the end of six weeks' convalescence was established. The only severe complication was a paralysis of the bladder which occurred during the third week of the disease and necessitated catheterization for two weeks. The remote symptoms were headache and disturbances of vision which ailments have since disappeared.

Treatment: For the relief of the pressure symptoms Tr. of Apocynum in 3 to 5 drop doses every 2 to 4 hrs. was given throughout the course of the disease. This was combined with various constitutional and intestinal antiseptics and alteratives as indications seemed to demand. Ice bags were applied to the head and neck.

The environment under which Mrs. S. lived was bad; the house was an old one, damp, and poorly heated. None of the family contracted the disease.

Case No. 2. Paul M., age 3 yrs., was first seen Nov. 26, 1909, when his symptoms were high fever, toxemia and prostration together with some rigidity of the neck and back which symptoms had been complained of a number of days. Kernig's sign was present. The patient would shriek loudly at times and particularly so at night.

A few days after seeing the patient an eruption of large macules spread discreetly over the body and remained about

four weeks. Two weeks after onset of symptoms aphasia supervened and lasted about two weeks.

The general condition of the patient improved gradually, but there were several severe relapses. However, convalescence was thoroughly established two months after onset of symptoms. Treatment: Tr. of Apocynum was given throughout the course of the disease in 3 drop doses every 2 to 4 hrs. During the first 2 weeks F. E. Ergot was used as a synergist to the Apocynum. The prompt though partial relief of the pressure symptoms was very marked and the toxemia much lessened. Alterative remedies, bathing, liquid or semi-solid diet, etc., were used as indicated.

Case No. 3. I simply wish to mention this case that I may show the prompt and effective initial action of Tincture of Apocynum. The patient, A. L., aged 11 yrs., had been well except for the ordinary exanthemata. He was first seen by me Mch. 26th, 1910, when he suffered from high fever, considerable prostration and delirium and slight rigidity of the neck. The next day this rigidity had extended to the back and was very marked. The intoxication, delirium, and severe prostration together with the rigidity of the neck were markedly relieved within thirty-six hours after beginning treatment. In four days the patient could sit up and seemed on the high road to recovery. However, an ambulance ride over a rough road seemed causative in inducing a relapse and recovery is yet problematical. Treatment has been practically the same as in the two cases above reported.

Resume: Tincture of Apocynum does not supplant specific sera. Its action here, if at all used, is supplementary.

2. In variant types of spinal meningitis its beneficient action is evident.

3. It relieves pressure in the cerebro-spinal cavities by producing rapid absorption and elimination.

4. It secondarily acts as a tonic to the circulation, facilitates the removal of toxins by action on the kidneys and bowels.

After Treatment of Appendicitis and Appendiceal Abscess.

*By P. A. SUNDBURY, M. D.. Holdrege, Neb.

All is not finished with the completion of the operation. Success or failure still largely depends upon the intelligent watchful after-care of the surgeon and nurse. Proper attention to seemingly trivial, although important, details during the fol

*Read before the Republican Valley Medical Society, at McCook, June 30, 1910.

lowing two or three weeks, will do much to shorten convalescence and restoration to perfect health.

I think there is a distinct reaction against the practice of hustling the patient out of bed in one week, when the majority of patients would be better off with at least two, or better three, weeks' confinement to bed and room.

The post-operative period needing the greatest watchfulness and care extends, in an average case, over the first five or six days. The first two or three of which the patient is getting over the shock of the operation and the nausea and vomiting caused by the anesthetic, and a day or two longer for the resestablishment of regular bowel action.

The patient should be put into a warm bed and surrounded with hot water bottles. If the pulse is good, no stimulants are needed, but in case of shock with feeble pulse, stimulants are needed in the form of coffee and brandy by the bowel, and strychnia gr. 1-10 to 1-30 hypodermically, every 1, 2, 3, or 4 hours, according to the urgency of the case.

I think it is good practice to allow the patient teaspoonful doses of hot water at frequent intervals, to allay the thirst, much sooner than has been the custom for the last few years.

All nourishment by the stomach should be suspended after the operation until the stomach is settled. The first food given should be egg albumen, prepared in the form of orangeade or lemonade, in teaspoonful doses at a time. In ordinary cases, about the third or fourth day, soft food may be given, and after the first week a stronger diet may be gradually resumed.

Severe pain must be relieved by morphine hypodermically in dose of, say 1-8 grain, repeated in 20 minutes if necessary during the first 24 to 48 hours, whenever the pain becomes unbearable. Of course, the less it is necessary to give, the better for the patient.

In the care of the wound, rest and protection are the two important factors. The dressings should be snugly applied so as to avoid sliding between the body and the dressings and thus avoid infection of the wound. If the patient has passed the hand underneath the dressings, immediate disinfection of the wound must be made and new dressings applied. If the patient complains of great discomfort and tenderness in the wound at the end of 48 hours, the wound should be inspected. This pain is not infrequently caused by an accumulation of blood serum beneath the skin or in the tissues. If this should be the case the blood should be allowed to escape and wound redressed aseptically and antiseptically. If at the end of 24 hours the dressings

are found saturated with blood or serum the external dressings. should be changed. The wound, however, is not in danger from infection from this source for about three days when all dressings should be changed.

While on this subject I would like to draw your attention to the fact that wound complications are apt to occur in persons with thick abdominal walls, because perfect hemostasis is not always obtained, and an accumulation of blood or blood serum may readily take place.

Wound infection may be either primary or secondary, superficial or deep, mild or severe. If, on the removal of the first dressings, the edges of the wound and the stitch-holes look red and angry and are tender to the touch, the wound is said to be infected superficially. If this occurs on the third or fourth day there may be no suppuration, but stitch-hole abscesses are sure to develop unless counteracted by treatment.

The inflamed parts should be mopped or irrigated with bichloride of mercury solution 1-1000, or Harrington's solution, and then a compress wet in bichloride 1-2000 applied on the wound and new dressings applied. This antiseptic cleaning and dressing should be repeated every day for three days. If first dressing has been postponed to between fourth and eighth days and stitching hole abscesses are found present, the same cleansing and dressing may have to be repeated twice daily until suppuration ceases, and then once daily until healthy granulation issue appears, when the antiseptic dressings should be iscontinued.

If the superficial infection is found to have extended deeply into the wound, it should be opened sufficiently to allow free drainage and the wound packed with iodoform gauze. Irrigation of the wound may also be necessary and may consist of either bichloride of mercury solution, 1-5000, iodine solution, potassium permanganate solution, normal salt solution, or others. The temperature of the irrigating fluid should be between 105 and 115 deg. F.

Wounds that are deeply infected from a primary source usually give rise to constitutional symptoms between the third and fourth day. The temperature may range from 99 to 103 or 104 deg. F., with chilly sensation, rapid pulse, pain and tender

*Read before the Republican Valley Medical Association in McCook, June 3, 1910.

ness. If at the end of 72 hours these symptoms are present, there is a clear indication for inspection of the wound, and if there is any undue prominence or tenderness the deep wound must be explored with all aseptic and antiseptic precautions, and if an ac