derstood. Thus an overdistended viscus anywhere is very apt to cause nausea. Pain in the hypogastrium and nausea are sometimes, nay often, the only symptoms indicating retention of urine. Nausea is Nausea is the only symptom discernible in some instances of an overloaded rectum.

I have often noted decided nausea accompanying pressure effects. Thus, I am now treating a case of pelvic cellulitis, in which there is considerable effusion with aterine retroflexion. The sudden supervention of nausea to a marked degree led me to suspect an aggravation of the local condition. This I found to be true, for the additional effusion had pinned the uterus down against the rectum. Emptying the rectum caused pain, as was to be expected, but it did not relieve the nausea, tho this was eased by the knee-chest position.

Extreme distension of joints from sudden effusions frequently causes nausea. The fact must ever be borne in mind that the distension must have been rapid enough to prevent adaptation if nausea is to be looked for. Unusual positions or motions of the body cause nausea, as in ocean voyages, in swings, and upon railway trains and trolley cars. The same is true of middle and internal ear diseases, notably of the semicircular canals, as in Meniére's disease, which is marked by the most pronounced vertigo.

Emesis-Vomiting.

Emesis being usually preceded by nausea, and being but an aggravation of this lesser symptom-or, rather, its natural sequence-what has been said about nausea applies equally to vomiting. But there are some points of difference, aside from the self-evident one, that nausea is the more frequent of the two, and often exists for a long time without ending in emesis.

But there are cases of vomiting that are not accompanied by nausea. These, then, require separate consideration. Some of the sudden explosive vomitings of cerebral disease, as in some cases of cerebral tumor, occur without any preliminary nausea. An irritant emetic often has the same effect. The child "throws up" (regurgitates) excessive quantities of food without any nausea. There is no mistake about this, for a sick stomach in a child cannot be misunderstood, because the child becomes pale, languid and listless to an extreme degree and loses interest in everything, whereas it does not necessarily

even interrupt its laugh when regurgitating food, and this regurgitation is simply vomiting without nausea. An overdistended adult stomach may likewise be unloaded without preliminary nausea.

There are numerous instances of vomit. ing preceded only by epigastric pain. I recall one instance in particular in which there was very intense epigastric pain in a woman nearly five months pregnant. It was so great that she could not get into bed, but sank beside the bed upon her knees and her arms upon its edge. Only a hypodermic injection relieved her at the time. A subsequent attack ended suddenly in vomiting, without the slightest nausea.

A. H. P. LEUF, M. D.

Philadelphia, Pa. [This article will be continued in subsequent issues.-ED.]

Unilateral Chorea-Coitus Per Urethram.

Editor MEDICAL WORLD:-In looking over my note-book, I find a couple of cases that were of unusual interest to me, being out of the usual routine. In a practice of over ten years I have never seen others like them in any particular.

CASE I.-Last June I was called to see a child, aged 20 months, with a history of chronic dysentery for two months. It had been dosed with domestic remedies ad nauseam. Its actions were dark green, and of a very offensive odor, and it was very much emaciated, having little or no fever, but disposed to be very stupid. Its kidneys were acting very little.

I was informed that the child had never been given any nourishment except what it obtained from the breast, and I found the mother's milk but very little more than water. I was further told that it had never been given a drop of water. I ordered it water, which, after a few efforts, it drank with avidity.

My first prescription for it was a few minute doses of calomel, to be followed with a dose of castor oil. This brought away a large mass of very offensive matter. I then put it on an antiseptic treatment, alternating with a mixture of elixir pepsin, bismuth and strychnin, and liquid pancrobilin. I also had it weaned and put it on Mellin's Food and malted milk. Under this plan of treatment it rapidly improved. But now comes the most inter esting part.

About a month after my last visit for

the dysentery I was again called, with the message that the child was having spasms. Upon my arrival, I found the child vastly improved in general health and mentally bright, but the left hand and foot were in a condition of constant tremor or spasm. It seemed a perfectly rhythmic relaxing and contracting of the muscles of those parts. I put it on antispasmodics, and, thinking the trouble might be of reflex origin, I had its bowels well emptied with castor oil. This failed to give relief. A few days later I saw it again, and found not only the left leg and arm involved, but also the left side of mouth, nose and eyelids; in fact, the whole left side was constantly twitching. There was a total lack of co-ordination in the movements.

The mental and physical condition of the child contraindicated any brain lesion. I could only diagnose unilateral chorea, or a constitutional disturbance similating chorea and caused by faulty nutrition. But why did it not come on earlier in the disease? Could the degenerative changes in the nerve and cell tissues continue and yet the general systemic condition be improving so rapidly? There was no motion of the head whatever, no. "nodding spasm." ." I have had it taking iron and a mixture of bromids and passiflora, and as soon as I can get the ripe berries I expect to give the tincture of horse nettle a thoro trial in this case. At this time, six weeks after the tremors began, there is no change except that possibly the eyelids are more at rest. I expect to keep close watch of the case.

CASE II. In the early summer, Mrs. W., white, aged 20, married nearly three years, came to me with a history of amenorrhea since December, '97. She stated further that menstruation had been very irregular ever since her marriage. She was weak and very anemic. I put her on a general tonic, as well as an emmenagog. A month later she returned, improved in general health, but had seen no sign of menses. She said she had suffered quite severely for three days during the time with pains indicative of menstruation.

As she objected to an examination, I kept up the same line of treatment for two months longer, with no result, except that each month for a few days she suffered as above stated. About ten days ago she came to my office again. I insisted upon an examination, rather expecting to find a pin-hole os. She readily consented. I

Index

found external genitals normal. finger readily entered the vagina, and, greatly to my amazement, I could find no os, only a blind pouch or culdesac not over four inches deep. To save me I could find nothing indicating the presence of a womb or any of the uterine appendages. I made further exploration with speculum with negative results. I also found that my finger very readily entered the urethra for about three inches, giving but little pain. Under very close and delicate questioning I elicited the following history:

66

She was perfectly healthy up to the age of fifteen; had never had her 'sickness before marriage, but occasionally had severe pains in lower abdomen. At this time her general health began to fail and she has not been well since. She says about four days after marriage her sickness came on for the first time, and she has had it a few times since-about four times, I think.

Coitus for the first few times was extremely painful and followed by the loss of blood, and each time she menstruated it was just after a very painful intercourse. I passt my fingers into the urethra and asked if there was where it hurt so much, and she replied "Yes." I then passt it into vagina and asked if it ever hurt her there; she replied "No." I feel sure that she has never had a true menstruation, but the fact that each loss of blood was preceded by a painful intercourse leads me to feel certain that at times the husband had intercourse in the urethra, thus causing the great pain, and the slight lacerations attendant thereto gave rise to what she supposed was her sickness.

Of course, under the existing circumstances, it was folly to attempt to force a flow-to attempt to force a part to perform its function, when that part was incapable of doing so. My treatment was not good, and yet, in the face of a refusal for an examination, how could I have done otherwise?

I believe that there are at least some of the uterine appendages in this person, but of course they are either infantile or very rudimentary in character. She has the physique of a woman, fairly good breasts, a distinctly feminine voice. I, of course, suspended all treatment, except purely systemic.

Now, what is to be the outcome of this case? She is already somewhat melancholy over her condition. My idea is that

unless she is very tenderly cared for that she will eventually go into a state of profound melancholia. Upon these points I laid great stress to the husband. If there are any of the appendages present, she cannot have good health, to say the least of it. My own opinion is-with the light and circumstances that are before methat an operation for the removal of what may be there, or at least an exploratory incision, is justifiable in this case.

Comments and opinions asked for. Success to THE WORLD.

JOHN H. HARDEN, M.D.

He had trouble in this ear for at least a month previous to my visit and about ten days before having a discharge from the ear. His lodge physician, judging from patient's description, had prescribed the injection of hydrogen peroxid and the insufflation of boric acid.

There was no evidence of discharge on my first examination. The external auditory canal was completely swollen shut and there was considerable swelling all around the ear, along the parotid gland and posteriorly over the mastoid process with no particular pain, but tenderness on pressure and "shooting pain," especially at night, thru the ear. The patient's condition otherwise was favorable, there being very little systemic evidence of the ear trouble.

I prescribed for him the following:

given him directions as to further treatment left him for a few days.

On my return, tho conditions looked still as favorable in general, to my surprise I found fluctuation over the mastoid process. I lanced this the next day, giving exit to considerable pus. On introducing a probe, the bone was found completely bare for about two inches all around the opening, and the discharge of pus during twenty-four hours was considerable. This not decreasing much during the next week, and with the possibility of caries and the necessity of cutting down in course of time, I thought it advisable to call a consultation.

After a careful examination we came to the conclusion that there was an opening into the antrum of the mastoid, and that our only hope lay in thoro cleansing with antiseptics and drainage of the wound. Having enlarged the wound I washed out solution in warm water of mercuric perthe cavity twice a day with a 1 to 4 or 5,000 chlorid, and after each washing introduced about a dram of ten per cent., fifteen per cent. of iodocrol (substitute for iodoform) in olive oil. Then I established drainage per rubber tube, and made the usual dressing of gauze, absorbent cotton and rubber tissue. Under this treatment for two weeks the pus got some less, but still there seemed to be a continual formation at a point near where the usual opening is made for opening the mastoid cells, in the angle formed by a line drawn up from the tip of the mastoid to strike the zygomatic arch.

We considered that the inflammation originally had begun in the external canal, spread thru the tympanum and thence to the mastoid cells and then thru the natural opening, affected the periosteum and scalp, and that now there was a considerable opening from which the pus seemed to come, principally a process which we hoped by drainage and antiseptics to check in course of time. We deferred, therefore, sending him to the hospital, but it was our intention to do so by March 1, when lo! the unexpected happened.

There formed a red patch, slightly swollen and tender, below the tip of the mastoid on the side of the neck. This redness and swelling soon spread over the ear on to the parotid region and thence in a few days over the whole face and foreheap. We had, in fact, a well-markt case of erysipelas with, of course, its usual symptoms. In one week this got partially well under ordinary treatment, viz.: applica

gr. viij 3v . 3j

3 ss q. s. 3iv

M. Sig.-3j in water every two to four hours.

The most peculiar thing in the case, and which, in fact, made me to report the case, was this: That as this erysipelas progressed the pus in the cavity lessened so perceptibly that it was more than accidental, and we sought around, of course, for an explanation. It was this-that the cause of the ear trouble was septic in origin (possibly from an abscess he had in his hand some four months before), and the erysipelas took from the blood the septic matter which formed the combustible material. We had strong hopes that the treatment instituted would eventually but tediously have arrested the destruction, but hardly so quickly and happily as by the unexpected complication. In two weeks' time from the care of the erysipelas the wound closed and the patient soon regained his usual health and spirits. Milwaukee, Wis. G. SCHMIDT, M. D.

The Abuse of Antipyretics. Editor MEDICAL WORLD:-I consider the indiscriminate use of antipyretics as unwise and positively dangerous. To prescribe these drugs in a hap-hazard sort of way, without judgment, is criminal. I refer chiefly to acetanilid, antipyrin and phenacetin. There is no profession, no calling, no business, no occupation that demands more care, thought, previous study, training and judgment than the practice of medicine, yet how few persons who prescribe medicines for the sick, consider the physiologic action of the drugs that they order.

After much close observation and study it is my opinion that this class of drugs weakens the heart muscle and breaks down the red blood corpuscles and finally produces heart failure. In many cases speedy relief is afforded at the expense of the heart and blood, and their continuous use after a certain period is not safe. When there is hyperpyrexia, as often occurs in typhoid, remittent and malarial fevers, congestion, etc., also severe congestive headaches and some other complaints, they

should be used in a limited degree. Their sphere of usefulness and prompt action cannot be denied when they are properly used. Their action should be carefully watcht and noted.

When relief from the severe symptoms is afforded in these cases, the remedy should be stopt. I have observed the feeble action of the heart following the continued use of this class of remedies— the increased anemia and the cyanosed condition. These preparations do not modify the course of disease, or act as curative agents. They simply give temporary relief during a certain stage, or during paroxysm of disease. Assuming such, why then prolong their use, except as indications require?

I write as I do concerning these medicines because it has often come under my notice that many physicians are prescribing this class of remedies indiscreetly, that is, to my way of thinking, as I have seen them prescribed for almost everything and everybody, without proper consideration. I have attributed the cause of death in a number of cases to the abuse of these drugs.

Another reason is the great sale of the different kinds of quack remedies and headache powders, put up by the druggists and given high-sounding names. Nearly every druggist has his own headache powders nowadays, besides half a dozen other brands on sale. Their main ingredient is acetanilid and their sale is simply enormous. I think the continued use of these powders shortens the lives of the people who use them, by producing heart weak

ness.

These powders are displacing the simpler and more harmless remedies, which in the majority of cases would serve the needs of the people much better. By the safer remedies I mean seidlitz powders, solution magnesia citrate, bromid of potassium and epsom salts. Dr. Abernethy, an old English physician, observed long ago that the safest and best way to relieve severe headaches was to open the bowels freely— to "bleed by the bowels" according to some-and I have found it a good rule to observe.

Dr. George B. Wood, an able and eminent physician in his day, was called in consultation by another physician in a case of enteric fever. He says: "It was agreed that the plan of treatment I proposed should be adopted. On my visit next day I was surprised to find the patient with the

In the first case of morphia poisoning I had after the permanganate was discovered to be an antidote, I used it hypodermically and my patient grew rapidly worse. was unable to swallow, and I had no syringe for injecting in the bowel, so I kept up the hypodermic treatment, with no beneficial effect whatever, altho I gave the remedy at short intervals. In about two hours after the morphia had been taken, he was dead.

I

We

I have since that time had one other case-an infant, about 14 months old. gave it, myself, morphia, hypodermically, for colic, and soon found that I had given too much. I immediately gave the permanganate of potash, hypodermically, but he grew rapidly worse and seemed to be dying. There were three or four other doctors in the house at the same time, having met there in a surgical case. all thought the child would surely die. There was no syringe in the house, so I drove to my office, fully five miles, and got a small rubber syringe, returning with all speed possible, and gave the permanganate per rectum. To prevent escape of the fluid, I held my thumb over the anus till the liquid was absorbed. Long before I thought to remove my thumb, I saw a decided change of symptoms.

Some of the other doctors present gave him another hypodermic injection while I was gone home after my syringe. They all told me it was too late to do him any good after I returned with it, and a more surprised lot of doctors I never saw before or since.

I give this, hoping it may be the means of some one saving a life. I do not claim that this is the best and only sure way of

A Case of Placenta Previa. Editor MEDICAL WORLD:-On January 17 I was summoned to come in haste to see a woman who was "flooding to death." On my arrival I found patient weak, anemic, with vision blurred from loss of blood. I soon found that woman was about six months' pregnant and was having pains that threatened immediate abortion. On examination I diagnosed central placenta previa.

As the woman had lost so much blood, and as the os was not dilated I decided to check hemorrhage and keep patient under close surveillance for a day or two. I checkt hemorrhage with ergot, strychnin and hot douches. I then gave some nitroglycerin to help the strychnin sustain the heart. This done, I gave one-quarter grain morphia sulfate, with 1-100 atropia, to relieve pains. This may not seem scientific treatment, but I thought the exigencies of the case demanded it and it workt like a charm.

The patient soon got quiet and went to sleep. After giving strict orders to call me should either pains or hemorrhage return I went to my office. I saw her again before bed-time and repeated orders to call me if anything transpired to require my presence. I saw her each of the two following days and neither pains nor hemorrhage had returned. I was forced to attend court, sixteen miles distant, on January 20, so did not see patient until 21st, when I learned that pains returned the night of 19th, tho lightly. The same symptoms appeared on the night of the 20th, but did not continue thru either day.

I advised forced delivery and asked for consultation. The woman would not consent to forced delivery nor to consultation, so I was forced to leave the case mainly to nature. After examination that showed some dilatation I again left the house but expected to be called at any time., I saw her again in the afternoon when she had no pains, but with nightfall the pains returned and I was called. I had ordered tampons of cotton to be used should