The

Danger of Loud Noises to the Very Sick. Dr. C. B. Morrisse, of Central Station Hospital, Trimulgherry, India, reports to the Indian Med. Rec. two cases of patients in a low state who expired immediately upon the occurrence of a sudden loud noise. We have no doubt that there are many patients whose cases are rendered distinctly worse by the various loud noises incident to city life, such as steam whistles, vehicles on rough streets,, hucksters' cries, the ringing of bells, etc., most of which disturbance is unnecessary. We believe, also, that many well persons, especially women and children, are rendered very nervous by these causes.

On account of the unusually urgent importance of our original communications this month we are compelled to omit the usual extent of editorial articles. In this we believe that our readers, when they peruse the following pages, will find themselves distinct gainers.

Original Communications.

Short articles on the treatment of diseases, and experience with new remedies, are solicited from the profession for this department; also difficult cases for diagnosis and treatment.

Articles accepted must be contributed to this journal only. The editors are not responsible for views expressed by contributors.

Copy must be received on or before the twelfth of the month for publication in the next month. Unused Manuscript cannot be returned.

Certainly it is excellent discipline for an author to feel that he must say all he has to say in the fewest possible words, or his reader is sure to skip them; and in the plainest possible words, or his reader will certainly misunderstand them Generally, also, a downright fact may be told in a plain way; and we want downright facts at present more than thing else.-RUSKIN.

Varieties of Pain.-Replies and Comments.' Editor MEDICAL WORLD:-A young physi cian consulted me for an affection of the legs. It began with pain, worst in the front of the thighs, not severe, worse on rising, and getting better towards evening. This was followed by anesthesia, not complete, worst in the feet. The legs were weak, and this to such a degree as to interfere with his attending to practice. There was some pain in the hips, about the sacro-iliao articulation, but none along the course of the sciatic nerves. On stooping, the patient said he felt as if "chords of his legs were too short." The general condition good, digestion normal, reflexes perfect, no ataxic symptons and no history of syphilis, alcoholic or other excesses. This case appeared to me to be one of a mild grade of peripheral neuritis, due to exposure to cold, while riding. The arms and upper part of the body get some exercise while riding, while the legs and feet get but little; hence the latter are likely to be chilled, and this is one result that may ensue. This case had been called "rheumatism," and as being due to exposure to cold. There is a certain appropriateness in the term, still it is wrong, for rheumatism is a disease of the fibrous structures of the joints, with local inflammation, fever, acid sweating and urine, and a tendency to shift from one joint to another. Nothing else is rheumatism; but with some persons "anything that hurts," receives this name, and under it we find the following:.

1. Neuralgia: Painful points where nerve passes through foramen, paroxysmal pains, confined to the course of one or more nerves, recurring in the same nerves and gradually implicating others, with anesthesias, trophic changes, attacks induced by depressing influences.

2. Myalgia, confined to muscles, in a state of degeneration from strain, overwork, disuse, or inflamed by "catching cold;" relieved by stretching.

3. Spinal irritation, diffuse tenderness, with pain on deep pressure over some vertebræ, in the epigastrium and in the left hypochondrium, arterial pulsations, reflex neuroses of the hysteric type.

4. Hypochondria: Pains periodic, affecting certain nerves but flying off to any point to which attention is directed, boring or burning paing, hyperesthesia to slight pressure, relieved by deep pressure

Locomotor ataxia: Lightning pains, with ocular palsies, altered gait, incoordination, crises of stomach, kidneys, bowels, heart, brain &c.

6. Cerebral abscess: Head pains; paroxys mal or a fixed burning, with convulsions, vertigo, paralysis, coma, cerebral vomiting.

7. Alcoholism: Pains not confined to same nerves, bilateral, not easily relieved by morphine, but speedily by alcohol, cord-like pains around ankles or wrists, a "shifty plausibility" of temper, and digestive troubles.

8. Syphilis: Bone-pains symmetrical, worse at night, pain on firmly pressing sternum, sensitive shins, painful points where nodes are forming.

9. Morphine: Abstention pains, attacking weak spots of superlative intensity, relieved by morphine in any dose, however small.

10. Gout: Pains in small joints, in meateaters of sedentary habits, with tophi and other gouty symptors

11. Lead: Colic, twinges of pain in forearms, lead-line on gums.

12. Uricemia: Frontal or occipital bilat eral headaches, gastric catarrh, aching and drawing sensations in limbs, stiffness, despondency, malaise.

13. Peripheral neuritis: Severe pain in one or many nerve endings, paroxysms of needle-like stabs, tingling, formication, burning, trophic charges in region supplied by affected

nerves.

When we call all these rheumatic or neuralgia, how much we lose of the nicety of medical practice. The treatment of these conditions is so various that they cannot be lumped together.

The neurotic condition underlying several requires nerve reconstructives, but these are worse than useless in uricemia or myalgia.

In the case of the young doctor, I attributed the symptoms to a mild peripheral neuritis, for which I recommended iodide of iron and arsenic, faradism and massage of the limbs with hot oil, hot bathing, moderate exercise and a good diet.

Dr. Tillotson's remedy (page 194), for diphtheria contains two useful ingredients-nitre and sulphur, but why not give these in the ordinary form? Sulphur blown into the mouth is highly valued by many authorities.

The condition described by Dr. Stratton (page 196) is not peculiar to diphtheria or a part of that disease. If any other infectious germs had come along, scarlatina, measles, or typhoid, the same depressed physiological condition would have proved the open door to them as well as to diphtheria. The iron-cholrine mixture is indeed useful as a systemic stimulant tonic, and in so far Dr. Stratton is right. The point I wished to emphasize in my letter was the neglect of local treatment induced by the belief in the constitutional nature of the disease.

Dr. Roberts (page 166), raises some very interesting questions. I may say that a healthy location is not necessarily synonymous with good hygiene. Cyrus Edson says there is not a well or spring in the United States where water is fit to drink. A mountain town in Pennsylvania was attacked with malignant diphtheria. I was assured by the doctors that the hygiene was faultless, but the State Sanitary Inspector found the drinking water contaminated with sewage. However, I do not wish to intimate that the doctor was mistaken in his belief of the healthy nature of the place, for that is not necessary. Country children are far more liable to the poison of infectious diseases than those who are inured to the polluted air of cities. Causes that would produce a mild case in the city child would develop the malignant form in the country cousin. So that the hygiene of the house may have been fully as good as the doctor claims, and still we can understand why the people have died. As to the cause of the outbreak in these isolated localities, it is one of the inexplicable mysteries. In all my experience there was never a case of smallpox that I failed to trace to its source. Nor were there many cases of scarlatina whose origin we failed to discover, but with diphtheria there were many whose coming remained a mystery. We could see the causes of malignancy, but whence came the contagion we could rarely tell. I am forced to the conclusion that the germs of diphtheria are widely scattered and retain their vitality for an unusual period, reproducing outside the body wherever a favorable nidus is found, and per

haps carried to a distance by the wind. In regard to Dr. Roberts' case, Horace W.: This was diphtheritic endocarditis. The bacilli penetrated to the blood-vessels, were carried away in the circulation, lodged on the valves of the heart, and there set up the pathological process that resulted in the boy's death. This, however, is totally different from the theory that looks on the disease as constitutional from the first, and the pharyngeal disease as only a local manifestation. The dysenteric cases may also have been diphtheritic. I think the chlorine acts locally on its way down the throat, and I use it thus instead of with a swab because it is a better way of reaching the whole pharyngeal tract, less unpleasant to the child, and the systemic effect ts also secured.

Dr. Page asks a remedy for calculi and goiter (page 204), caused by the magnesio-calcic water of Kansas. If people will drink this water they may expect to suffer. I would advise the use of distilled water, were I not afraid the Kansas farmer might utilize his still for the production of agents more dangerous than magnesia water.

On page 211 Medicus asks about the treatment of congenital hydrocele. I would let it alone until some time had elapsed, some years, infact, unless there is some reason for immediate operation. For some years I have treated all hydroceles by drainage, tapping with a fine trocar and leaving the little silver canula in the wound until adhesive inflammation has obliterated the sac.

Today I received a letter from a patient in Pennsylvania who says the medicine I sent him for chronic alcoholism, works like magic; the craving has disappeared and he is sleeping and eating like a coal heaver.

Dr. Pinto's case (page 217) looks like one of bulbar, or as we used to call it, glosso-laryngopharyngeal, paralysis. If so, she will die, and no treatment will give relief.

Dr. Thompson (page 218) has resurrected. that wonderful man, Howard Green, who had the misfortune of being born many years too soon. When he described his method of intralaryngeal applications, his competitors cooly concluded that he lied, as the laryngological specialty was not then born. In the old text. books you will find mention of him.

As disinfectants before going to the obstetric room, I prefer sanitas for the clothes and peroxide for the hands. But the old fashioned chlorinated soda is excellent. In fact, it is not so much the choice of antiseptic as its perfect application and perfect cleanliness, that are es sential. I have never yet known a case of vomiting of pregnancy that required abortion. I have known many women who would not have

got any relief from other treatment if they thought that they could have abortion performed as a last resort. Quite recently I dilated the sphnicter ani and thus cured an obstinate

case.

For lupus exedens, described by Dr. Small (page 219), I would apply trik resol locally and give theiosinanine by bypodermic injection, dressing with permanganate and earth or charcoal.

Dr. Smith will not find an albolene atomizer expensive, and if he uses it with Dobell's solution and then with compound albolene spray, he ought to cure his catarrhs quite nicely.

For such cases as Dr. Cochran's (page 219), there is but one remedy, the rest cure, with its accessories, as carried out in a well-conducted sanitorium. WILLIAM F. WAUGH, M.D., 103 State St., Chicago.

Intestinal Obstruction.

Editor MEDICAL WORLD:-By this is meant a complete stoppage of the passage of the contents of the bowels, by tumors or other matters inside of the bowel or around it and inside of the cavity of the peritoneum. The books give many causes, but many of them have not been apparent to all practitioners, such as floating kidneys-a very rare occurrence-displaced spleen, mesenteric and ovarian tumors, cancers, but not entanglement in peritoneal openings as hernia, constricting bands of connective tissue, incarceration of bowel or by apertures in omentum mesentery or diaphragm, suspensory ligament of the liver, broad ligament of the uterus, &c. Many other causes, but these are enough. The balance can be referred to in the books on the subject.

Symptoms: The most prominent is pan, (though some times it is not very acute, thereby misleading the practitioner), colicky and increased by pressure,; vomiting, first of the contents of the stomach-then of bile, some times very slight when the obstruction is in the rectum or colon, which allows the fecal matter to be thrown up by continued vomiting; tympanites

occurring as the disease progresses. Examinations ought to be made under anesthetics, either ether or chloroform. Owing to the rigidity of the muscles of the abdomen, anesthetics are absolutely, necessary unless the other symptoms leave no mistake in making the diagnosis. Sometimes examination by the rectum is necessary. In case of intussusception it may happen that the discharge of blood may make it difficult to distinguish from dysentery. For more particular and extended symptoms I would refer to Dr. Ashurst's valuable report in the

Polyclinic and copied in the Epitome to Braithwaite of 1886.

The face is pale and has an anxious expres sion; features pinched as in violent diarrhea and cholera; eyes sunken in the sockets; pulse rapid and feeble; tongue dry; urine scanty and high colored. In chronic obstruction from impaction of feces these symptoms are milder and sometimes without any vomiting. When from tumors pressing on the bowel a change of position may temporarily relieve the obstruction, but it generally ends in debilitated health,

anemia &c.

Diagnosis. This is sometimes difficult, from hernia-not very prominent-from stricture or a tumor or tube of the sigmoid flexure. A case of the latter was reported at the Johns Hopkin's Hospital. The operation revealed no obstruction of the bowel but a pancreatic tumor around the bowel. Bilroth reported a case of cancer of the bowel in which six inches of it was removed and the ends of the bowel stitched together, with recovery to the patient. The diagnosis is difficult as of the particular lesion, as the same symptoms generally are found in obstructions generally, but more certain in strictures and in invaginations of the bowel. If volvulus, it is considered impossible, but more probable in strangulation. I had a case in which one part of the bowel passed over another part, before the days of treatment by Laparotomy, and only revealed by a post mortem. A writer in the Boston Medical and Surgical Journal says that the diagnosis of the seat of the obstruction is rather less difficult than its nature. It is based on the determination of the capacity of the colon, which, under anesthesia, may be made to contain six quarts, a pressure of a column of water in adults of twenty feet, in children of twelve feet, being probably safe. It should be remembered that the rectum alone may contain one and a half quarts. If four to six quarts can be introduced, the obstruction is almost certainly at or above the cecum. The earlier the procedure is resorted to the less likely is gaseous extension to prevent its full application or injury to follow its imployment. On the other hand, the more likely is it to be of therapeutic service, as in intussusception.

2. The situation of the tumor, if such be present, may throw lights on the seat of the obstruction.

3. But little reliance is placed on the symp. toms. It may perhaps be stated that the higher the seat, other things being equal, the less the urine and the tympanitis. When tenderness first appears, its location may have some value as indicating the advent of peritonitis, which is apt to start at or about the lesion.

The presumable value of the obstruction has some bearing on the seat of the obstruction. Intussusception involves the large intestine in 90 per cent, of the cases. Strangulation of the small intestine in same proportion. Gall stones

and foreign bodies obstruct the small intestines alone. All other kinds are much more common in the large intestines, and all, save fecal impaction, are more apt to involve one or the other end of that portion of the canal. Satistics show that four fifths of all acute obstructions are found in the lower abdomen.

First in importance is the diagnosis of the condition, that purgatives may be avoided and surgical interference (if necessary) may be resorted to before the patient's chances are imperiled by notable peritonitis or changes in the nutrition of the gut itself. Next in importance, though not in procedure from pain, is the nature of the obstruction. Intussusception alone offers much chance of medical or expectant treatment. A determination of the seat determines also the point of elimination, of comparatively subordinate importance.

1. Örter reports 34 out of 295 obstructions to be of strangulation as analyzed by Fitz. Of 101 cases-there were 63 adhesions-villettine remained at 71. Seventy per cent. are in males; 30 per cent. in females, showing that muscular work produces most cases. Ninety per cent. are in the small bowel; 57 per cent. in the right iliac fossa and 83 per cent. in the lower abdomen.

2. Intussception varies from half an inch to a foot or more. Ninety-three out of 295 cases of acute intestinal obstruction were due to this cause; 57 in males and 27 in females. Thirtyfour per cent. were under one year of age and 55 per cent. under 10 years of age. Fortytwo were uncertain as to causes.

3. Of twists and knots were there 42 out of 255 cases; 68 in males and generally between 30 and 40 years of age. Fifty cases were in the sigmoid flexure.

4. Of strictures, fifteen out of 295 were in the large intestine and four congenital stricture; two single stenosis, four ulceration &c.; three new growths, epethelioma &c.; four compression and traction of tumors of neighboring organs.

5. Abnormal contents, foreign bodies, fruit stems, coins, pins, needles, false teeth. 6. Round worms.

Accumulation of medicines, magnesia bismuth, feces, gall stones, enteroliths, 23 cases of gall stones in eight years, 18 in women and 5 in men and 17 after the fiftieth year of

age.

The obstruction from worms may be difficult to detect from intussusception, as the symptoms