[We do not think the subject sufficient for an entire number, but shall be pleased to publish any useful articles in regard to it that we may receive.-Ed.]

Dr. G. E. Matthews, of Ringwood, N. C., wishes to know the best treatment for the "hot flashes" of the menopause.

Dr. Field, of Elroy, Wis., wishes treatment to remove powder stains from the face. The testimony of those of our readers who have tried the many plans published in this journal some years ago would now be in order.

A writer wishes for recent advanced information in regard to the treatment of scarlet fever.

Request is made for formula of "Pinkham's Compound."

Editor MEDICAL WORLD:-Will you please insert in your columns this case :

Female, age, 23; one child 5 years old; then married 3 years after; now has child 4 months old She has had an enlargement of right axillary glands, extending or swollen down the side and across to the mamary gland; the pains shoot over to the breast and down the side. She is not so much ematiated, but some, which may be owing to nursing the child. The glands of the axillary regions, where the lump is, are tender to the touch. It has been there for four years, small; but since the birth of the last child it has enlarged very fast and become painful. Is it malignant in character, or is it just enlarged glands? J. C. MOLLYNEAUX, M.D., Woodland, Ill.

[Any specific taint?-Ed.]

Editor MEDICAL WORLD:--As I desire to prepare a paper on Epistaxis as a complication in diphtheria affecting the nasal cavity, would ask any one who has had experience in

the matter or can give briefly the views of authors in their possession to write me what they know about it, including treatment. consider this a grave and generally fatal complication and one but little discussed in medical works. Please write me personally, and I will arrange the matter in a manner useful to all, omitting names if desired, and if the editor of THE WORLD thinks it worthy of a place in these columns, will publish it.

Missouri Valley, Ia. R. D. MASON, M.D.,

Elitor MEDICAL WORLD:-I was called November 1st, to see Mr. J. He had been troubled since the early spring with head and back ache, had been treated by various physi cians, but on July 1st had to give up work. I found him in bed suffering greatly from head ache, pain between the shoulders and on each side of the back, low down and in the calves of the legs, muscles twitching about the shoulders and at different points in the lower limbs. Vision was perfect. I also found that he had a very long and tightly contracted prepuce, which was swollen and inflamed. He was passing large quantities of colorless urine, specific gravity 1002, Bowels only moved once in seven or eight days, and then only a small slug. Appetite very poor. Troubled with insomnia, and very despondent. I removed the foreskin and the wound healed nicely; primary union. After the first months treatment urine became normal, in quantity and quality, bowels regular, and appetite good, painless and muscular twitching stopped. I then expected by the aid of tonics to have my patient able to go to work in short order, but I have been fooled. headache still continues and he has a good deal of pain in various parts of the body and legs. The least exercise makes him feel tired and languid, and causes the pain to return. He is a young man of exemplary habits; never has been intemperate; family history good; never has been any syphilitic disease or received any injury. Their is no tenderness at any point along the spine, and he has never had any trouble with the eyes. Readers of THE WORLD, I want help. Give me your diagnosis, treatment and prognosis. M.

His

Editor MEDICAL WORLD:-Will some of your readers please give me a reliable formula for the cure of the tobacco habit?

J. M. F.

Editor MEDICAL WORLD:-I have been an uninterrupted subscriber to THE WORLD ever since the first number was published, and cannot now do without it. Sharon, Ga. A. C. DAVIDSON.

Editor MEDICAL WORLD:-Will the readers kindly give me advice iu the following case:

Mr. A., 32 years of age, married; in youth practiced self-abuse and since marriage has indulged to excess. He suffers from nocturnal emissions, and the fluid passes when at stool or with the least pressure. His condition is such as usually results from excessive indulgence.

I am a young man in the profession and have had no experience with such cases heretofore and therefore ask THE WORLD and its readers for information as the remedies I have used, have had no effect on the patients condition.

ADVICE.

Editor MEDICAL WORLD:-I would like to know the following:

an averagely informed doctor, for pregancy? If the stomach presented an enlargement, symetrical and well defined, the exact shape of pregnancy, a firm feeling as if the finger pressed upon an enlarged uterus; this enlargement and well rounded and well marked line of firmness extending up nearly to the navel, and the parts between this and the ensiform cartilage perfectly flaccid and soft, would not this show pregnancy? If it was a swelling from fever, tympanitis, etc., would not the tension in an enlargement of the above extent, extend to ensiform cartilage? INTERROGATOR

Dr. Ray, of Côte St. Paul, Montreal, Canada, wishes formula for Koenig's Nerve Tonic.

2. What medicines can be given to a pregmant woman without injuriously affecting the fetus?

3. What medicines are absorbed in the milk when given to a nursing mother, without injuring the baby. For instance, can tincture of aconite or tincture of veratrum, strychnine, etc., be given to the mother without affecting the nursing babe?

4. What is the best treatment for suppressed or arrested lochial flow?

5. How many of THE WORLD's subscribers believe in the physician's furnishing his own medicine, for profit and to prevent reduplication of prescription by druggists, and for convenience and profit to patient?

6. What is the best formula for a cough medicine, basis, syrup and balsam of fir?

7. What is the best solvent or vehicle for tar in a cough medicine?

8. Does the occurence of menstruation during a case of pneumonia lessen the chances of recovery?

9. What effect does the occurence of menstruation have upon the treatment or prognosis of any and all acute diseases-grippe, fever, pneumonia, etc.?

10. What is the best and purest make of salicylate of sodium?

11. What are the indications for the use of diascorea villosa (wild yam), and the best preparations of the same? Is the solid extract as active as the fluid extract and tincture? What is the dose of each?

12. Could any sequela or condition of typhoid or other fever, in the eighth week, produce an enlargement of the stomach, simulating preg. nancy of four or five months? That is, could tympanitis, enlargement, etc., be mistaken by

Croupous Pneumonia.

The following are the conclusions of Dr. R. N. Cunningham, of Evsly, Ala., at the close of his article in the Va. Med. Monthly:

"1st. It is a constitutional disease, with a local anatomical sign, consisting of an inflam mation of the pulmonary parenchyma, and caused by its own specific materies morbi or germ, probably that of Frankel or Friedlander.

2d. That the special circumstances under which this germ is evolved and operates are unknown, as we have it under diametrically opposite conditions, both good and bad.

3d. That the disease as a rule, prevails endemically, rarely epidemically, and still more rarely sporadically.

4th. That these endemics differ in type and in extent of pulmonary inflammation, and consequently, in mortality.

5th. That the disease is severer in public institutions, especially prisons.

6th. That the negro is especially predisposed to the disease, has less capacity to resist it, and, consequently, a larger mortality.

7th. That coal miners, especially negros, while not predisposed to the disease, are favorsble subjects for extensive pulmonary inflammation, and have less capacity to resist the disease, owing to the more or less anthracosis of the pulmonary tissue.

8th. That the mortality is mainly determined by the type of the disease; first, in the primary effect of the germ upon the nervous system; and secondly, the extent of pulmonary inflammation and in the rapidity of its invasion and develop

ment.

9th. That the mild, uncomplicated cases, with a fairly good pulse and moderate temperature,

and with only one lobe, especially the lower lobe, involved, intrinsically tend to recovery; and that the severe cases, complicated or not, with fast and weak pulse, fast or labored respiration, regardless of temperature and attended by great prostration, intrinsically tend towards death, and without judicious treatment will die, regardless of the extent of pulmonary inflammation; and that in the cases in which the pneumonia is double, particularly if the double invasion is simultaneous, their tending is to a fatal issue; and finally, that in the cases in which the inflammation is universal by a simultaneous or rapidly successive invasion of the entire lung structure, death is the inevitable rapid result. Therefore, in comparing statistics, all these things shsuld be taken into account; otherwise they are worthless. Hence the wide divergence in the statistics and difference in treatment of various observers.

10th. That the immediate cause of death in many cases is ante mortem heart clots.

11th. That the main features of treatment

are: (a) to combat the shock of the germ invasion, best done by opium, stimulants, and, in my opinion, hypodermoclysis or the subcutaneous injection of a saline solution-chloride of sodium drams j to the pint of water. So far as

I know this is absolutely new in the treatment of this disease. (b) to stimulate freely, the best stimulant, as a matter of routine, being whiskey and strychnine, supplemented in extreme cases by tincture strophanthus; (c) to control temperature, the best method being the bath; (d) to prevent, if possible, heart clots, hypodermoclysis, in my opinion, being the most reliable; (e) to meet indications as they arrise."

The doctor reported an endemic of this disease among convicts which subsided immediately after a thorough antiseptic cleansing of the prison. Speaking of hypodermoclysis, he says: "In studying this disease two facts-one clinical and the other pathological-were impressed upon my mind: 1st. The prostration in this disease greatly resembled surgical shock. 2d. The chlorides are always diminished in the urine, as the disease advances, usually in proportion to the extent of pulmonary inflammation, reappearing in correspondingly increasing quantities during resolution. It occurred to me, therefore, that if this prostration were treated after the manner of treating shock, and that if the blood were supplied with additional chlorides, the heart clots might be prevented. Both of these indications seemed to be met by the introduction into the blood of a warm saline solution. I, therefore, determined to inject into the veins or arteries—after the manner of treating surgical shock or hemorrhage-a warm,

aseptic salt solution of the strength given above. At the suggestion of Dr. Jerome Cochrane, State Health officer, I adopted hypodermoclysis as the method, using a fountain syringe and a medium-size aspirator needle as the instruments and the subcutaneous tissue of the abdomen as the site for the injection."

Infectious Nature of Croupous Pneumonia.,

As erysipelas develops in the lymphatic channels of the epidermis, typhoid and cholers localize in the intestine, pneumonia is limited to the lungs: there the invasion of the exciting agents of pneumonia begins, and as it is certain that corpuscular matter can pass from the acini to the lymph channels of the lungs in pneumonia, it penetrates with facility into the fluids of the body.

Pneumonia is a disease due to infection, but whether purely contagious or miasmatic is a question. It is beyond doubt due to microorganisms, and must be classed with cerebrospinal meningitis, erysipelas, mumps, influenza and rheumatic fever.-Macfarlane, in Brooklyn Med. Jour.

Treatment of Renal Insufficiency.

Dr. Rochester (New York Medical Journal) says:

We should not try to stimulate into activity an organ that is inflamed or degenerated, by the use of drugs that excite functional activity of such organ; in the case of the kidney we should rarely, if ever, have recourse to stimulating diuretics, or to diuretics which, like digitalis, act by increasing the arterial pressure, until we have relieved the venous congestion by diaphoresis or catharsis, or both.

Attention to diet is of the utmost importance in these cases.

In order that the materials to be excreted by the kidney may come to that organ in the most unirritating form, the metabolic processes should be carried to completion; this is to be accomplished by regular systematic exercise, which is to be obtained by massage when active exercise is not advisable, by inhalations of pure oxygen gas when it is evident that sufficient oxygen is not obtained from the air, and by the dilution of the katabolic materials by drinking large amounts of distilled water or one of the mildly alkaline waters.

The anemia that accompanies these cases should be met by the use of oxygen and iron.

As the symptoms indicative of this condition are the result of toxemia which depends upon

the non-elimination from the body certain katabolic materials that should normally be carried off through the kidneys, and as these organs are in such condition that they cannot do their work, all other avenues of elimination should be opened up for the escape of these poisons. This is to be brought about by exciting the activity of the skin by means of hot air or steam baths accompanied and followed by vigorous massage; keeping the bowels open by means of salines and washing away the contents of the colon, thus keeping the mocous membrane in a proper condition for excretion, with copious enemata of slightly alkaline water, occasionally followed by a high enema of 500 or 600 c. c. of pure olive oil, as suggested by Fleiner (Berliner Klin Wochenschr., 1893, Nos. 3 and 4).-Am. Lancet.

Two Easy and Delicate Tests for Albumin in Urine.

Dr. C. Fouchlos (La Progres Medical) recommends two new tests for albumin in urine, for which he claims utmost delicacy and absence of any possibly fallacy.

1. Add to the suspected urine a few drops of a 1 per cent. solution of corrosive sublimate; in case of turbidity, add some drops of acetic acid. If the turbidity persists it is due to the presence of albumin.

2. Take 100 cc. of a 10 per cent solution of sulpho cyanide of potassium, and mix it with 20 cc. of acetic acid. Add a few drops of this mixture to the urine. If albumin is present in small quantities, an immediate tubidity will ensue; if in large quantities, a heavy white precipitate will appear.-E. C. R., in Med Review.

Cause of Death From Bullet Wounds of the Brain.

A London correspondent writes in the Am. Pract, and News that Mr. Victor Horsley maintains that the cause of death from bullet wounds of the cerebral hemispheres is due to the sudden increase of intracranial pressure brought about by the entrance of the bullet into the cavity of the skull, a cavity which was closed and already full. As an experimental demon

stration of this he showed that when a closed cavity filled with water and lint was fired into, the increase of internal pressure manifested itself by the bursting of the canister with great

violence. The increase of pressure in the brain took effect on the respiratory center, which becoming paralyzed, death ensued.- West. Med. Reporter.

Erysipelas and Gonorrhea

Schmidt (Contralblatt fur Gynakologie, 1893, No. 39) reports a case of gonorrheal vaginitis in a little girl in whom erysipleas of the thigh

developed with simultaneous disappearance of the viginal discharge. Vaginitis is known to be a peculiarly intractable affection in children, yet in this instance it was cured within a few days without local treatment, and there was no recurrence after the disappearance of the erysipelas. The apparent causual relation between the latter and the cure of the gonorrhea is analogous to the effect of the inflammation in cases of inoperable sarcoma.-Am. Journal Med Sciences.

[This is another example of the scientific fact of disease antagonism, mentioned frequently in these pages recently.—ED.]

The Inch-and-a-half Incision and Week-and-a-half Confinement in Append.ctis.

BY ROBERT T. MORRIS, A.M, M.D.

More than a million dollars have been paid to expert consultants who made the diagnosis of typhoid fever, idiopathic peritonitis, typhlitis, or internal strangulation of bowel in cases in which the disease was really appendices. Consequently, that money was expended to no pur pose by the patients.

More than a million patients have died of appendicitis because the consultants made other diagnosis at a time when prompt operation would have saved life. Consequently, these deaths were unnecessary.

We cannot realize how common appendicitis is until we have rubbed our eyes and looked about a bit. Within the past five years I have removed fourteen infected appendicitis for the patients of one venerable physician, who in more than thirty years of practice had not previously made the diagnosis of appendices, and I believe him to be a representative practitioner who has had no more than an average propor

tion of the cases under his care.

One of the most vivid pictures in my memory is that of a celebrated German anatomist with

scalpel in hand making a postmortem examina tion and noting points which were jotted down in the record book by his assistant. The cecum of the cadaver was covered with thick, gray

lymph, The appendix was not examined be cause it happened to be buried in pus and adhesions, and because it was only a little thing. anyway. "Perityphlitis!" said the professor. "Perityphlitis," mumbled the assistant as he put the note where it would go on record.

It was only a decade ago that we began to examine infected cecums closely enough to collect accurate data; and then followed the era in which rules for finding inguinal pus were elaborated, in the intention of operating for the

evacuation of pus when it was discovered. How well we remember the day when authorities were ranged along the line of argument as to whether abscesses in appendicitis were extra-peritoneal or intra-peritoneal. Later information was to the effect that the patient's chances for recovery were better when the appendix was removed before pus got on any side of the peritoneum. Then we tried different waiting periods before operating, and these periods became shorter and shorter because we were often made sorry, for when we waited to see how a case would turn out we often found out. We found out that the patient was going to die because we had waited too long; or that he was going to recover. But we never, never, never knew when the patient had recovered, and that was a sticker for honest counsellors. By rational deduction we are to-day aware that the appendix should be removed as soon as a diagnosis of appendicitis can be made. No important question of late years has received more summary treatment than the one as to the proper time for operation in ap pendicitis; and as the question is wedge shaped, with deaths grouped at the late end, we have slid quickly down to the point which on my indicator rests at the words "no delay." In the evolution of the prompt operation for removal of an infected appendix I have reached a position from which it seems best to ask surgeons to accept as standard, an abdominal incision one inch and a half in length, which confines the patient to his room for a week and a half. It is not necessary to repeat here in detail my theory of appendicitis, which, briefly stated, describes the disease as an infectious exudative inflammation of the appendix vermiformis ceci, caused by bacterial invasion of a structure which is not well equipped for self-defense. The reason why bacteria gain entrance into the tissues of the appendix is because the guarding mucosa of that structure is easily bruised between a full cecum and a hard pelvic wall, or it is eroded by concrements. The reason why the appendix is not well equipped for defense is because the inner tube of mucosa and adenoid tissue is so closely confined within the outer tube of muscle and peritoneum that it cannot swell much without cutting off its own vascular supply and causing a resulting train of effects.

Appendicitis once established may continue to smoulder for years without causing any important symptoms, or it may blaze up and destroy the patient in a jiffy. Usually the disease smoulders for years and blazes up from time to time. Medical treatment smothers the blaze frequently, but the smouldering continues while the patient believes himself to be well. Sometimes the patient is not deceived, but his physi

cian is; and when these patients come to us for operation, without the knowledge of the family physician, it is often difficult for us to persuade them that it is best to have his counsel and assistance in the case.

The inch and a half incision is made through the right linea semilunaris and all structures of the abdominal wall The colon is readily distinguished by its longitudinal muscular bands. The direction of the colon is determined by exciting reversed peristalsis with a crystal of sodic chloride. The appendix is always found exactly where the long muscular bands of the cecum terminate. Adhesions are separated with a finger introduced into the abdominal cavity. If pus is present, or if adhesions are widely attached, or if the appendix is attached to the gall-bladder, or left overy, the inch and a half incision must be discarded for a longer one; but the longer incision is the exception in the class of cases that I am getting nowadays mesentery of the appendix is ligated with fine cat-gut The base of the appendix is ligated very close to the cecum with a fine strand of eye silk to prevent intestinal contents from seeping into the wound. The ligated stump is buried with three Lembert sutures, for, if it were not so buried, perforation occurring under the ligature might cause trouble. The abdominal wound is closed with separate tiers of fine cat-gut sutures for the separate structures of the abdominal wall. If we used a single tier of sutures for aponeuroses which pull in different lines of traction, the patient would not be out of bed at the end of his week and a half.

The