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A NOTE ON THE TREATMENT OF DIPHTHERIA.
1368 can hardly fail to be a serious falling off in the number of new members, since the Royal Society is able to offer so much more to its Fellows, while the Medical Society can offer little if anything which cannot be obtained by the Fellows of the amalgamated societies. I would therefore suggest that the matter should be recon. sidered while this can be done without loss of dignity, and that no pains should be spared to ascertain the opinion of the whole of the Fellows of the society, and I hope that other Fellows of the society will publish their views on this I am, Sir, yours faithfully, question. CHARLES W. BUCKLEY. Buxton, May 3rd, 1908.
Some observers have noticed instead of the usual periodicity of migraine a continual succession of the attacks which has been called the 11 status hemicranicus" by the school of Charcot, on the analogy of the "status epilepticus."Mobius quotes a case in which the patient had five attacks of migraine in five successive days. After an interval of some months there was another series, which led to a kind" of stupor, and finally there was a third series consisting of nine attacks in four days ; at the same time there was a complete hemiplegia.1 Kraft-Ebing speaks of epileptic hemicrania and hemicranial epilepsy having the same visual aura and seems to imply that there is but one disease, though sometimes migrainous, at others epileptic symptoms predominated in a given case ; he says that the visual aura may occur alone or end in a hemicranical or epileptic attack or both.2 I am, Sir, yours faithfully, R. O. MOON. Green-street, W., May 4th, 1908.
there
.
i
, Ii
A NOTE ON THE TREATMENT OF
DIPHTHERIA.
~
To the Editor of THE LANCET. 8lR,—No remedy is more sorely needed than one which will relieve the distressing condition of heart paralysis in diphtheria. Several years ago Dr. J. D. Rolleston1 warmly recommended adrenalin in this affection, and Dr. F. G. Crookshank has found occasion in your issue of April 25th to reaffirm his own convictions as to the great benefit of this treatment. In view of the importance of the question at issue it would not be right to allow these statements to pass without a thoroughly critical examination of the remedy
WORTH’S ADVANCEMENT OPERATION. To the Edito’l’ of THE LANCET. have at least as great an objection to ellJ cathedra statements as Mr. Claud Worth and I may point out that anonymity finds its justification in the elimination of personal motives which are, at any rate, absent in the present instance. The fallacy which in my opinion characterises Mr. Worth’s in common with many other advancement operations is that in the ordinary operation the stitches tear out through the and thus lead to an unsatisfactory result. I am conmuscle vinced that failure is not due to the stitches tearing out through the muscle, which is supported by resistant connective tissue, but to their giving way at their anterior attachment. Here, unless a firm hold is obtained upon the episcleral tissue the stitch is almost certain to cut out, no matter how secure may be its attachment to the muscle. Mr. Worth has mentioned the chief objection to his operation, and if it is carefully considered it is no small one. His knots strangle the lateral parts of the muscle which must necessarily atrophy and are further lacerated in removing the stitches. For my part I am convinced that the secret of success in advancement operations is obtaining a firm hold on the episcleral tissue. I do not propose to pit any individual surgeon’s practical experience against Mr. Worth’s, for in such matters there is but little faith to be put in personal authority. It is the duty of every surgeon to weigh the advantages and disadvantages of any given procedure and to adopt the method which appears to him to be best. I am, Sir, yours faithfully, YOUR REVIEWER. May 2nd, 1908.
SiR,—I
suggested.
In the first place Rolleston’s observations on the prophy. lactic and stimulant effect of the drug must have been received with some surprise, since the method of administration was by the mouth, and it is generally understood that by this channel the drug is practically inert, being either altered or unabsorbed. Dixon2 found that, given by the mouth, adrenalin had no effect upon the blood pressure, even after the administration of one drachm-six times the maximum dose recommended. From experimental evidence, then, it seems most unlikely that any effect whatsoever is produced. Practically, I have given the drug a very fair test. In the course of a close study of the heart complications in more than 500 cases of diphtheria at Nottingham I had occasion to test the effect of adrenalin and several other cardiac tonics. Rolleston’s directions were faithfully followed but nothing but negative results were obtained, the disease always pursuing its normal course, sometimes with bradycardia and low blood pressure and sometimes ending in collapse. It was evident, however, that the rise in blood pressure and pulse-rate that regularly occurs after the first week or so in hospital might easily be wrongly attributed to the effect of some cardiac tonic. I am aware, however, that Dr. Crookshank, while endorsing Dr. THE ROYAL SOCIETY OF MEDICINE AND Rolleston’s results, prefers hypodermic injections, combining the adrenalin with a little strychnine. But again we have THE MEDICAL SOCIETY OF LONDON. the testimony of DixonJaneway, Elliott, and others that To the Editor of THE LANCET. the action of adrenalin injected subcutaneously is purely SIR,-I should like to suggest through the medium of your local, except in very large doses. Upon these two suggested columns, to the Fellows of the Medical Society of London, improvements in his methods we might justifiably turn some that the time has come to consider further whether they are soundly practical but drastic criticisms employed by acting in the best interests of the society as a whole in holdhimself in a similar connexion. Of the frequent ing aloof from union with the Royal Society of Medicine. hypodermic injection he hints that it is an 11 unjustifiable The reasons, so far as one could gather, which led to their annoyance, since it interferes with the euthanasia which it attitude at the time of the inception of the latter society is our duty to promote." And of strychnine-that "you " were mainly financial but I think that the remarkable might as well paint the bed with it1 I might continue in success which has attended the formation of the Royal the same vein and of adrenalin happy say something about Society must have put any question of its financial stability its perfect harmlessnesa as a beverage. quite out of court, while sentimental considerations which As regards early heart paralysis and the inutility of cardiac may not unnaturally have weighed with the older members stimulants it must be remembered that "cardiac depression" should not be allowed to assume an undue prominence. Apart is a very misleading term to apply to this condition. It is from my own personal feelings, conversation with other not depression but actual dest’l’twtion of tissue from which the Fellows of the society has shown me that a strong feeling heart suffers. This destruction is apparently progressive, as exists (which in many cases will develop into withdrawal in other and reaches its acme about diphtheritic paralyses, from membership) that the interests of the society and of its the ninth or tenth day, as evidenced by appearances post members would have been better served by union, and mortem and by the fact that at this time the blood pressure certainly the opinion of the Fellows which was taken by I and pulse-rate both reach their lowest points and the means of postcards showed a very large majority in favour greatest number of deaths occur. All depressing toxic of amalgamation. The general meeting which was called to substances are presumably long since neutralised. I have consider the question was, however, chiefly attended by the little doubt from a keen study of these phenomena that the opponents of the scheme, very many of its advocates failing bradycardia of this period is Nature’s rest-cure and, moreto attend from a belief that amalgamation was a foregone over, a contrivance for eking out the energies of the heart conclusion. wall lest they should be spent before this danger-point is There is no doubt that the majority of those who favoured union will, like myself, still stick to the Medical Society, but 1 See article, Diphtheritic Paralysis, Practitioner, p 794, vol. ii., 1904, 2 THE LANCET, March 24th, 1906, p. 826. 3 Ibid. 1 Nothnagel’s Pathologie, vol. xii. 4 2 Vide supra. Neurologisches Centralblatt, 1895.
Rolleston
I
1369
passed by and
the heart, whether it be given in a teaspoonful of in a pint, but this is not the case with chloroform administered by inhalation. It is common knowledge that if chloroform be given in concentrated vapour it is much more dangerous than if given largely diluted with air. One strychnine and other stimulants in several hundred cases, I drachm administered by one person may produce a fatal have treated nearly 400 cases completely without these result in the same time that one ounce administered by drugs and my results will compare favourably with any I another person does. I am quite aware that if this be have seen published. Unless a remedy can be found that reasoned out it will amount to a question of dosage, yet will replace destroyed tissue cells with new ones it seems practically it is extremely misleading, especially to students only likely that the quest of a remedy for these cases will ever and lay people suchuseasis coroners and their juries. The remain a hopeless one. percentage or concentration. Now to justifiable term to return to this graduated drop method, as we are told that after I am, Sir, yours faithfully, a few minutes the lint may be allowed to rest lightly on the OWEN H. PETERS, M.D., Ch.B. Melb., D.P.H. Lond. face the system practically amounts to this, that the means of Mansfield, May 4th, 1908. dilution of the chloroform is to remain the same throughout the administration, while the amount of chloroform is to be SPINAL OF CASES ANALGESIA. FIFTY increased. It is important to grasp this as the principle is To the Editor of THE LANCET. exactly the opposite of that in the next method to be SlR,—In my article upon Fifty Cases of Spinal Anal- described. Now if anyone will take the trouble to try this gesia appearing in your issue of April llth I made the method on himself he will find that with the lint so close to statement that M. Billon had ceased to manufacture the his face it is almost impossible to get anything but a constovaine solution himself and had handed over the work to centrated vapour even though only a couple of drops are put This statement, which was offered as a on the lint, and I am sure this will be greatly to the a firm in Paris. possible explanation of what I supposed to be a certain detriment of the patient’s safety. feebleness in the analgesia resulting from the use of a The other method is one I may say that is used in Edinsecond consignment of the solution from Paris, was made on burgh. The great underlying principle in this method is the strength of what I believed at that time to have been that the amount of’ chloroform used remains uniformly the reliable information. It gives me much pleasure to be able same throughout the administration. Thus an equal amount to contradict both statement and supposition. M. Billon, who of chloroform-say, half a drachm-is put on the mask at has been courtesy itself in affording me assistance and in equal intervals, say, one minute. The varying percentage of placing samples at my disposal, writes to me to say that not chloroform vapour required for the case is got by altering the only has he never dissociated himself from the work but distance of the mask from the face (from two inches or more that he has been, since the beginning of 1907, director of the to half an inch). This method is the one that seems to me chemical laboratories of Messrs. Poullenc Freres in Paris, by far the safest, for one has only to try it on oneself with a where the manufacture of the solution is entirely under his Schimmelbusch’s mask to be convinced that one can adjust immediate direction and control. With regard to the supposed the percentage of chloroform vapour inhaled much more difference in strength of the solution above mentioned, I am accurately than one can by the graduated drop method. satisfied by extended experience of the method that this This method has been accused, especially by the advocates of supposition was an entirely mistaken one, and that it was the drop method, of being unscientific, but I am sure the partly due to faulty technique on my part, and partly to the above remarks will show that it is essentially scientific and a fact that some patients are less susceptible to the drug than method thoroughly to be recommended. others and require a slightly larger dose. I am, Sir, yours faithfully, I therefore hasten to offer an apology to M. Billon and beg M.B. EDIN. April 30th. 1908. you, Sir, to give early publicity to it, as I fear that my statement may quite unintentionally have produced a wrong DIRECT MEDICATION OF INTESTINES. impression and one which might prove detrimental not only To the Editor of THE LANCET. to M. Billon himself but to the firm of Poullenc Freres. I am, Sir, yours faithfully,SiR,—MetchnikoN’s contention that most of the diseases LAWRIE MCGAVIN. Mansfield-street, W., May 2nd, 1908. which afflict the human family may be ascribed to the bacterial flora of the large intestine is coming to be conAutotoxoemia due to the presence of sidered plausible. DEATHS DURING ANÆSTHESIA. bacteria in the colon, "that clumsy effort of the evoluTo the Editor of THE LANCET. tionary process," is probably far more common than is interested in the that been discussions have generally supposed. The Russian biologist believes that a SIR,-I deeply have recently appeared in THE LANCET on the subject of future age will be able to remedy by surgical procedure the chloroform administration. In the letters that have been imperfect attempt of nature to provide an efficient cloaca published many have expressed opinions more or less strongly maxima for man. Meanwhile intestinal germicides and disinfectants offer a reasonable means of combating some of the on the cause of death from chloroform anaesthesia ; a smaller number have given the bald details of how they themselves evils caused by the parasites in our system. For direct medicaadminister it, but no one, so far as I have noticed, has tion of the intestines keratine has long been used to enwrap attempted to define or to criticise the underlying principles drugs intended to pass through the stomach unaffected by its connected with the various practical methods of its: acid secretions, but readily soluble in the alkaline juices of administration. Now, these principles are of the utmostj the bowels. In the treatment of a case of mucoid colitis I value for comparing the various methods and for devising have lately prescribed salol in five grain doses inclosed in A great improvement was quickly new and safer methods, and I think that the statements: membranous envelopes. given below must be productive, by means of the discussion I. noticed in the condition of the patient, due, I believe, hope they will arouse, of some advance in our knowledge of, to the action of the phenol liberatedInby the disintegration of the salol in the intestines. my opinion very practical chloroform administration. The first method which I wish to criticise is one inl good results are to be expected in this comparatively It would be interesting to fresh field of therapeutics. common use and goes under the name of the "graduatedl series of drops " system. In this system one drop of chloro- experiment systematically with lactic acid as an intestinal I am, Sir, yours faithfully,form to begin with is put on a piece of lint ; after a few germicide. ___’_J M.D. seconds two drops are added, then three drops, and so on April 17th, 1908. till a maximum number of drops is reached. It is also recommended that after a short time the lint be allowed to rest lightly on the patient’s face. The object is, of course, MEDICAL DEFENCE UNION.-The annual general to begin with a very small dose and gradually increase it to meeting of the Medical Defence Union will be held on a maximum. At first sight this appears quite rational, but I May 21st at the Medical Institution, Hope-street, Mount am convinced that the underlying principle is quite wrong. Pleasant, Liverpool, at 4.30 r. M. The annual report of the It is founded on the belief that you can talk of the council, together with the balance-sheet and accounts as dose of chloroform in the same practical sense that you certified by the auditors, will be presented to the members can talk of the dose of digitalis or hydrocyanic acid. and the usual statutory business as required by the articles of 15 minims of the tincture of digitalis will have the same association carried out.
the processes of repair set in. Flogging on by stimulants, when practically nothing remains to stimulate, can only prematurely deplete its energies ; stimulants call forth but do not add to the energies of an organ. For my own part, after witnessing the uselessness of the heart
effect
on
water
or
--
,
,
.
,
7
Some observers have noticed instead of the usual periodicity of migraine a continual succession of the attacks which has been called the 11 status hemicranicus" by the school of Charcot, on the analogy of the "status epilepticus."Mobius quotes a case in which the patient had five attacks of migraine in five successive days. After an interval of some months there was another series, which led to a kind" of stupor, and finally there was a third series consisting of nine attacks in four days ; at the same time there was a complete hemiplegia.1 Kraft-Ebing speaks of epileptic hemicrania and hemicranial epilepsy having the same visual aura and seems to imply that there is but one disease, though sometimes migrainous, at others epileptic symptoms predominated in a given case ; he says that the visual aura may occur alone or end in a hemicranical or epileptic attack or both.2 I am, Sir, yours faithfully, R. O. MOON. Green-street, W., May 4th, 1908.
there
.
i
, Ii
A NOTE ON THE TREATMENT OF
DIPHTHERIA.
~
To the Editor of THE LANCET. 8lR,—No remedy is more sorely needed than one which will relieve the distressing condition of heart paralysis in diphtheria. Several years ago Dr. J. D. Rolleston1 warmly recommended adrenalin in this affection, and Dr. F. G. Crookshank has found occasion in your issue of April 25th to reaffirm his own convictions as to the great benefit of this treatment. In view of the importance of the question at issue it would not be right to allow these statements to pass without a thoroughly critical examination of the remedy
WORTH’S ADVANCEMENT OPERATION. To the Edito’l’ of THE LANCET. have at least as great an objection to ellJ cathedra statements as Mr. Claud Worth and I may point out that anonymity finds its justification in the elimination of personal motives which are, at any rate, absent in the present instance. The fallacy which in my opinion characterises Mr. Worth’s in common with many other advancement operations is that in the ordinary operation the stitches tear out through the and thus lead to an unsatisfactory result. I am conmuscle vinced that failure is not due to the stitches tearing out through the muscle, which is supported by resistant connective tissue, but to their giving way at their anterior attachment. Here, unless a firm hold is obtained upon the episcleral tissue the stitch is almost certain to cut out, no matter how secure may be its attachment to the muscle. Mr. Worth has mentioned the chief objection to his operation, and if it is carefully considered it is no small one. His knots strangle the lateral parts of the muscle which must necessarily atrophy and are further lacerated in removing the stitches. For my part I am convinced that the secret of success in advancement operations is obtaining a firm hold on the episcleral tissue. I do not propose to pit any individual surgeon’s practical experience against Mr. Worth’s, for in such matters there is but little faith to be put in personal authority. It is the duty of every surgeon to weigh the advantages and disadvantages of any given procedure and to adopt the method which appears to him to be best. I am, Sir, yours faithfully, YOUR REVIEWER. May 2nd, 1908.
SiR,—I
suggested.
In the first place Rolleston’s observations on the prophy. lactic and stimulant effect of the drug must have been received with some surprise, since the method of administration was by the mouth, and it is generally understood that by this channel the drug is practically inert, being either altered or unabsorbed. Dixon2 found that, given by the mouth, adrenalin had no effect upon the blood pressure, even after the administration of one drachm-six times the maximum dose recommended. From experimental evidence, then, it seems most unlikely that any effect whatsoever is produced. Practically, I have given the drug a very fair test. In the course of a close study of the heart complications in more than 500 cases of diphtheria at Nottingham I had occasion to test the effect of adrenalin and several other cardiac tonics. Rolleston’s directions were faithfully followed but nothing but negative results were obtained, the disease always pursuing its normal course, sometimes with bradycardia and low blood pressure and sometimes ending in collapse. It was evident, however, that the rise in blood pressure and pulse-rate that regularly occurs after the first week or so in hospital might easily be wrongly attributed to the effect of some cardiac tonic. I am aware, however, that Dr. Crookshank, while endorsing Dr. THE ROYAL SOCIETY OF MEDICINE AND Rolleston’s results, prefers hypodermic injections, combining the adrenalin with a little strychnine. But again we have THE MEDICAL SOCIETY OF LONDON. the testimony of DixonJaneway, Elliott, and others that To the Editor of THE LANCET. the action of adrenalin injected subcutaneously is purely SIR,-I should like to suggest through the medium of your local, except in very large doses. Upon these two suggested columns, to the Fellows of the Medical Society of London, improvements in his methods we might justifiably turn some that the time has come to consider further whether they are soundly practical but drastic criticisms employed by acting in the best interests of the society as a whole in holdhimself in a similar connexion. Of the frequent ing aloof from union with the Royal Society of Medicine. hypodermic injection he hints that it is an 11 unjustifiable The reasons, so far as one could gather, which led to their annoyance, since it interferes with the euthanasia which it attitude at the time of the inception of the latter society is our duty to promote." And of strychnine-that "you " were mainly financial but I think that the remarkable might as well paint the bed with it1 I might continue in success which has attended the formation of the Royal the same vein and of adrenalin happy say something about Society must have put any question of its financial stability its perfect harmlessnesa as a beverage. quite out of court, while sentimental considerations which As regards early heart paralysis and the inutility of cardiac may not unnaturally have weighed with the older members stimulants it must be remembered that "cardiac depression" should not be allowed to assume an undue prominence. Apart is a very misleading term to apply to this condition. It is from my own personal feelings, conversation with other not depression but actual dest’l’twtion of tissue from which the Fellows of the society has shown me that a strong feeling heart suffers. This destruction is apparently progressive, as exists (which in many cases will develop into withdrawal in other and reaches its acme about diphtheritic paralyses, from membership) that the interests of the society and of its the ninth or tenth day, as evidenced by appearances post members would have been better served by union, and mortem and by the fact that at this time the blood pressure certainly the opinion of the Fellows which was taken by I and pulse-rate both reach their lowest points and the means of postcards showed a very large majority in favour greatest number of deaths occur. All depressing toxic of amalgamation. The general meeting which was called to substances are presumably long since neutralised. I have consider the question was, however, chiefly attended by the little doubt from a keen study of these phenomena that the opponents of the scheme, very many of its advocates failing bradycardia of this period is Nature’s rest-cure and, moreto attend from a belief that amalgamation was a foregone over, a contrivance for eking out the energies of the heart conclusion. wall lest they should be spent before this danger-point is There is no doubt that the majority of those who favoured union will, like myself, still stick to the Medical Society, but 1 See article, Diphtheritic Paralysis, Practitioner, p 794, vol. ii., 1904, 2 THE LANCET, March 24th, 1906, p. 826. 3 Ibid. 1 Nothnagel’s Pathologie, vol. xii. 4 2 Vide supra. Neurologisches Centralblatt, 1895.
Rolleston
I
1369
passed by and
the heart, whether it be given in a teaspoonful of in a pint, but this is not the case with chloroform administered by inhalation. It is common knowledge that if chloroform be given in concentrated vapour it is much more dangerous than if given largely diluted with air. One strychnine and other stimulants in several hundred cases, I drachm administered by one person may produce a fatal have treated nearly 400 cases completely without these result in the same time that one ounce administered by drugs and my results will compare favourably with any I another person does. I am quite aware that if this be have seen published. Unless a remedy can be found that reasoned out it will amount to a question of dosage, yet will replace destroyed tissue cells with new ones it seems practically it is extremely misleading, especially to students only likely that the quest of a remedy for these cases will ever and lay people suchuseasis coroners and their juries. The remain a hopeless one. percentage or concentration. Now to justifiable term to return to this graduated drop method, as we are told that after I am, Sir, yours faithfully, a few minutes the lint may be allowed to rest lightly on the OWEN H. PETERS, M.D., Ch.B. Melb., D.P.H. Lond. face the system practically amounts to this, that the means of Mansfield, May 4th, 1908. dilution of the chloroform is to remain the same throughout the administration, while the amount of chloroform is to be SPINAL OF CASES ANALGESIA. FIFTY increased. It is important to grasp this as the principle is To the Editor of THE LANCET. exactly the opposite of that in the next method to be SlR,—In my article upon Fifty Cases of Spinal Anal- described. Now if anyone will take the trouble to try this gesia appearing in your issue of April llth I made the method on himself he will find that with the lint so close to statement that M. Billon had ceased to manufacture the his face it is almost impossible to get anything but a constovaine solution himself and had handed over the work to centrated vapour even though only a couple of drops are put This statement, which was offered as a on the lint, and I am sure this will be greatly to the a firm in Paris. possible explanation of what I supposed to be a certain detriment of the patient’s safety. feebleness in the analgesia resulting from the use of a The other method is one I may say that is used in Edinsecond consignment of the solution from Paris, was made on burgh. The great underlying principle in this method is the strength of what I believed at that time to have been that the amount of’ chloroform used remains uniformly the reliable information. It gives me much pleasure to be able same throughout the administration. Thus an equal amount to contradict both statement and supposition. M. Billon, who of chloroform-say, half a drachm-is put on the mask at has been courtesy itself in affording me assistance and in equal intervals, say, one minute. The varying percentage of placing samples at my disposal, writes to me to say that not chloroform vapour required for the case is got by altering the only has he never dissociated himself from the work but distance of the mask from the face (from two inches or more that he has been, since the beginning of 1907, director of the to half an inch). This method is the one that seems to me chemical laboratories of Messrs. Poullenc Freres in Paris, by far the safest, for one has only to try it on oneself with a where the manufacture of the solution is entirely under his Schimmelbusch’s mask to be convinced that one can adjust immediate direction and control. With regard to the supposed the percentage of chloroform vapour inhaled much more difference in strength of the solution above mentioned, I am accurately than one can by the graduated drop method. satisfied by extended experience of the method that this This method has been accused, especially by the advocates of supposition was an entirely mistaken one, and that it was the drop method, of being unscientific, but I am sure the partly due to faulty technique on my part, and partly to the above remarks will show that it is essentially scientific and a fact that some patients are less susceptible to the drug than method thoroughly to be recommended. others and require a slightly larger dose. I am, Sir, yours faithfully, I therefore hasten to offer an apology to M. Billon and beg M.B. EDIN. April 30th. 1908. you, Sir, to give early publicity to it, as I fear that my statement may quite unintentionally have produced a wrong DIRECT MEDICATION OF INTESTINES. impression and one which might prove detrimental not only To the Editor of THE LANCET. to M. Billon himself but to the firm of Poullenc Freres. I am, Sir, yours faithfully,SiR,—MetchnikoN’s contention that most of the diseases LAWRIE MCGAVIN. Mansfield-street, W., May 2nd, 1908. which afflict the human family may be ascribed to the bacterial flora of the large intestine is coming to be conAutotoxoemia due to the presence of sidered plausible. DEATHS DURING ANÆSTHESIA. bacteria in the colon, "that clumsy effort of the evoluTo the Editor of THE LANCET. tionary process," is probably far more common than is interested in the that been discussions have generally supposed. The Russian biologist believes that a SIR,-I deeply have recently appeared in THE LANCET on the subject of future age will be able to remedy by surgical procedure the chloroform administration. In the letters that have been imperfect attempt of nature to provide an efficient cloaca published many have expressed opinions more or less strongly maxima for man. Meanwhile intestinal germicides and disinfectants offer a reasonable means of combating some of the on the cause of death from chloroform anaesthesia ; a smaller number have given the bald details of how they themselves evils caused by the parasites in our system. For direct medicaadminister it, but no one, so far as I have noticed, has tion of the intestines keratine has long been used to enwrap attempted to define or to criticise the underlying principles drugs intended to pass through the stomach unaffected by its connected with the various practical methods of its: acid secretions, but readily soluble in the alkaline juices of administration. Now, these principles are of the utmostj the bowels. In the treatment of a case of mucoid colitis I value for comparing the various methods and for devising have lately prescribed salol in five grain doses inclosed in A great improvement was quickly new and safer methods, and I think that the statements: membranous envelopes. given below must be productive, by means of the discussion I. noticed in the condition of the patient, due, I believe, hope they will arouse, of some advance in our knowledge of, to the action of the phenol liberatedInby the disintegration of the salol in the intestines. my opinion very practical chloroform administration. The first method which I wish to criticise is one inl good results are to be expected in this comparatively It would be interesting to fresh field of therapeutics. common use and goes under the name of the "graduatedl series of drops " system. In this system one drop of chloro- experiment systematically with lactic acid as an intestinal I am, Sir, yours faithfully,form to begin with is put on a piece of lint ; after a few germicide. ___’_J M.D. seconds two drops are added, then three drops, and so on April 17th, 1908. till a maximum number of drops is reached. It is also recommended that after a short time the lint be allowed to rest lightly on the patient’s face. The object is, of course, MEDICAL DEFENCE UNION.-The annual general to begin with a very small dose and gradually increase it to meeting of the Medical Defence Union will be held on a maximum. At first sight this appears quite rational, but I May 21st at the Medical Institution, Hope-street, Mount am convinced that the underlying principle is quite wrong. Pleasant, Liverpool, at 4.30 r. M. The annual report of the It is founded on the belief that you can talk of the council, together with the balance-sheet and accounts as dose of chloroform in the same practical sense that you certified by the auditors, will be presented to the members can talk of the dose of digitalis or hydrocyanic acid. and the usual statutory business as required by the articles of 15 minims of the tincture of digitalis will have the same association carried out.
the processes of repair set in. Flogging on by stimulants, when practically nothing remains to stimulate, can only prematurely deplete its energies ; stimulants call forth but do not add to the energies of an organ. For my own part, after witnessing the uselessness of the heart
effect
on
water
or
--
,
,
.
,
7