is established; here we need a lower per cent. of fat and a very high per cent. of proteid. I should recommend for these cases food prepared from the top wo ounces of a quart, which contains about 20 per herent. of fat, diluting with eight times as much preigested gruel for the first two weeks, and six times. As much for the last two. The formulas for such Dod, prepared from an average milk, are:—

(A) 2.75 per cent. fat, 0.50 per cent. proteid. (B) 3.66 per cent. fat, 0.66 per cent. proteid. Don't add any sugar the first two weeks, as colosum contains only 4 per cent. sugar. The per cent. proteid here is far from corresponding to the ount of proteid in colostrum. It is, as said bere, impossible to modify cow's milk in such a way to obtain as high a per cent. of soluble proteid Ar albumin) as is found in colostrum; therefore, only thing to do is to reduce the insoluble pro1 (casein) of cow's milk to a figure correspondto the same in mother's milk. 6 SOUTH STREET.

JCTOR IN MEDICINE AND THERAPEUTICS AT THE NEW YORK POST-
ADUATE MEDICAL SCHOOL AND HOSPITAL; ATTENDING PHYSICIAN
TO THE NORTH EASTERN DISPENSARY, DISEASES OF THE
HEART AND LUNGS.

competition thrust upon us by grandmas, 'um agents, prescribing druggists, patent cine makers, quack physicians, the patient himand, in short, everyone, should make us alive e thought that something is radically wrong the laity's opinion of our skill, and this itself to the depression of our finances. I had alforgotten to mention what thrives in the large the ten, twenty-five and fifty-cent doctor. all these we must compete, not forgetting the als, clinics, and free dispensaries, which are ous and attract crowds, notwithstanding the to keep out all but the worthy poor, which the main, futile.

v what makes all this obtain? We will say, s examinations of patients by the physician, at any of us would intentionally be guilty of ch breach of contract with our clients—but ✓ examinations make poor diagnosis and sis and furnish a bad standard on which to any therapeutic measures for the relief or f disease. This is the reason why people · from hospital to hospital, clinic to clinic, ary to dispensary, and physician to physieking in vain for aid for their ills, and it is ne cause for the physicians losing patients

5.

will instance what is meant by careless exon—the patient goes to see a physician, givstory of the case, and the physician inquires condition of the bowels, sees the tongue, e pulse and temperature, inquires about the d takes the fee, and if luck attends the man the patient, perhaps, gets well. This, at extent, has been heard from patients e all see, and we see the great field for efore the Mt. Vernon Medical Society.

patent medicines which, when taken by the dozens of bottles, are supposed to work marvelous cures. Maybe through improper teaching, unknown normal characteristics and signs the physician is to prescribe in exactly the above way, and many a patient has run to different medical men with the same result until meeting the expert diagnostican; then, and then only, by proper therapeutic methods, has been relieved or cured.

The cause of cursory examination is the improper teaching of physical diagnosis in Our medical schools, more especially in undergraduate colleges, although there are exceptions to this as to every rule. The student is not given ample acquaintance with normal signs and sounds, especially those of the breast and lungs, and this being true, how can he be expected to differentiate from them diseased. conditions? An instance of this is afforded in the following: A physician, freshly graduated, came to one of our post-graduate institutions to take a course in general medicine; in course of time he was given a perfectly normal case to examine and the suggestion made to pay particular attention to the heart, the result of his examination gave every pathological cardiac condition possible, except rupture of that organ. Again, I myself have had students tell me that they have felt, seen, and heard, conditions that were positively present, although it was plain to me that they did not-they were too modest to follow the old motto "If at first you don't succeed, try, try again."

All this ought to be changed, and the student should be taught thoroughly the normal physical signs, those of the organs not only of the chest, but also of the abdomen and pelvis, and they should use instruments of precision. The physician, who has been carelessly taught physical diagnosis, should endeavor to teach himself or be taught normal physical diagnosis, and when expertness in that subject has been reached, then, and only then, start in and study and learn pathological physical diagnosis. This, in my opinion, is the way that the physical examination of the patient should be taught in all our medical colleges; but is it so at present?

During our visit with the patient I believe that, following the subjective examination of the case, we should also make a careful objective one, going through a systematic routine of the suspected field: (1) Inspection, (2) palpation, (3) percussion, (4) auscultation, and (5) any other means necessary to afford an exact diagnosis, such as mensuration, urine testing, both microscopical and chemical, the use of the sphymograph, etc., and should not diagnosticate a condition on the subjective examination only plus the five cardinal points of pulse, temperature, bowels, sleep, and tongue.

In inspection, the examiner should not, as we have times without number noticed, stand in front of the patient and inspect only the anterior surface, but he should survey the body from all points noticing every minute sign. And on palpation, nothing is gained by laying on of the hands heavily, as we have seen done.

Percussion seems to be one of the bugbears of the medical man, and the method of percussing from the whole arm, as I have often seen, is to be deplored, for the only rational and resonant tone is produced by striking from the wrist alone. We be

lieve the use of pleximeter and percussion hammer to be far superior in most hands to the system of using one hand as the hammer and the other as a pleximeter.

Auscultation by some having a very acute ear can be practised to a great extent by that organ alone, but even here the use of a first-class stethoscope, phonendoscope, and other instruments of that type with well-adapted ear-pieces, serves the purpose far better for most of us than the human organ of hearing alone.

By means of instruments of exactness the expert can make the diagnosis of pulmonary tuberculosis from one to six months before the x-ray has shown the evidences of the disease. Sometimes we get vague histories, incomplete, and maybe no history at all in cases-as when the foreigner seeks our aid and he speaks not our tongue, neither do we hisand in such class of cases we have to depend on physical examination alone as a basis of diagnosis, prognosis, and treatment. The following case is cited: A man, about 45, born in Turkey, no history obtainable. Inspection: Chest emaciated, breathing difficult; chest moves as one piece, barrelshaped, myodoma. Palpation: Increased vocal fremitus. Percussion: High-pitched and short percussion note. Auscultation: Prolonged inspiration and expiration, high-pitched crepitant râles, rough in character; increased vocal resonance. Taking all these signs, we diagnose his case as one of emphysema, and also make a prognosis.

Now what are the indications for treatment, and how are they best met? Improve breathing by gymnastics and massage; remove mucus by expectorants; to remove thickened tissues use iodides; to build up the body give food; as regards climate, moderate elevation is best. I have cited this case to show how important is physical examination, not only in diagnosis but also in prognosis and treat

ment.

Now as to therapeutics. Numerous as are our cases and troubles, none is worse than the agent who fills our waste baskets with literature and our offices with samples. Some of these compounds, no doubt are good and are being used and deservedly, but in the long run, diet, exercise, and the use of old and tried remedies of the Pharmacopœia, in short, intelligent therapeutics, with a few grains of common sense are far better for your patients and we know why we attain results. The materia medica of the Pharmacopoeia has not been tried and always found wanting, therefore let us not get the craze of wading in the sea of nostrums, but stick to the old manner of writing prescriptions, and thereby knowing what our patients are using, until something infinitely better attains; when it does we may use it. The reason for the popularity of the nostrum is that it is more pleasant to take, pleases the æsthetic eye, the druggist or chemist does the thinking, etc., but we can meet those demands by a little more careful prescribing

and addition of aromatics.

In giving directions to patients, be clear, and it seems to me better not only to explain why you are using certain methods, but also instead of telling them to take a medicine so many times a day or at intervals of so many hours, to indicate the exact times it should be taken. If you do so, the patient

will aid you very materially. Do not do, as a friend of mine did in explaining to a lady about chlorosis and after a thorough explanation told her, “Madame you want to get blood," whereupon she exclaimed as she suddenly left him, "But, doctor, I could never drink that." Another time, a near relative of mine. while attending a clinic for rheumatic conditions, was consulted by an old Irish lady, who was rather t of comprehension, and she was told after he ha prescribed for her and handed her the prescription to rub this on the painful joint thoroughly. Abr one hour after, upon leaving, he noticed her s there and inquired of her the cause; when told him that she had rubbed the knee thorough with the paper with no result whatever.

These are simply brought forward to show h very important it is to have the patient thoro understand what should be done and how to d in the line of exhibiting not only medicines, but is all therapeutic aids which may obtain in the part lar case, and you yourself should be sure that thoroughly understands everything that you explained and told him to do just as well as p know your indications and how to meet the

Some years back cardiac diseases were a of great worry and fright to the laity as well the profession, but at present they are handel's successfully by the physician that the patient on under proper therapeutics until the end term of their natural life, without much from the diseased organ. Sir Andrew Clark numerous patients with heart disease which to green old age without any particular distr In the practise of an esteemed colleague and t was a case of aortic stenosis, which was under care of his grandfather from 1830 to 183 uncle from 1856 to 1882, and himself from to 1893, when the patient died at the age having been under the care of the first physic twenty-six years, the second for twenty-six and the third for eleven years; a total period

years.

This has been brought about by careful e mentation and study of those conditions, the tion for and means of combating them, same is true in all other departments of at the present day. The percentage of being brought down in most all diseases, because more careful examinations are being and proper therapeutic treatment instituted. at the present writing we find that in pre under the creosote treatment the perce deaths is from five to eight. But physicians want to see a death rate in all diseases of if there was no fear of dying, we would be of starving; nevertheless, it is our duty to st all diseased conditions not only from the pr side, but also for the purpose of curing e we possibly can.

My deeply respected colleague was read a paper on typhoid fever at an occasi kind, and in it brought forward that he ha cent. of deaths; when in the discussion lowed it came out that in a county of 13.00 * according to the statements of the differer cians practising there, every man, woma had had typhoid during the year at least each and none of them had died.

The

advised operating. With the assistance of my colleagues, Drs. Doughty and McClintock, the operation was done on the thirteenth day of the fever. After the peritoneum was incised and the cæcum drawn up and out of the wound, the appendix presented itself, standing up in the wound like an inflated rubber finger cot. It was quite congested and enlarged in caliber, and about 41⁄2 inches long. The omentum was sutured and the appendix amputated, the wound being closed in the usual manner. appendix was carefully examined, and cut up on a director; the mucous coat was soft and broken down, and the outer two inches contained a considerable amount of pus. The operation was done on the afternoon of June 16, and the temperature during the night fell to 100°, and at my morning visit on June 17, at 9 o'clock, it was 98.2°. During that day it rose again, and at 5 o'clock on the morning of June 18 it was again 103°. Going up during the day, it reached 104° at 5 p. m. From this time on, as the chart will show, there was a more or less regular typhoid run of fever, with its usual smyptoms. Quinine was given every four hours, and strychnine sulphate (1-50 gr.) every four hours. Surgically, nothing of interest occurred, the superficial stitches were removed on the seventh day, and a good, strong, healthy wound was found. On the twentyfifth day the temperature went twice to the normal point, and after that, during convalescence, did not vary much.

I have thought the case worthy of record, as I have never seen or known of the two diseases occurring together, and I think the coincidence must be very rare.

Why the temperature went to subnormal even for a few hours, the day after the operation, I am at a loss to understand, unless is was that the appendix was so large an additional focus of infection, and its removal so relieved the system that the fall occurred for a short time.

is anæmic. The treatment of fibromata is essentially s gical, and the necessity for operation is realized more and more. Total or partial hysterectomy has more advocates than have other methods. The benign character of firemata seems incontestable if one considers the origin, structure, and etiology of the tumor. The writer believes that the indications for myomectomy are very limited. Myomertomy is really indicated only when the fibrous nodules are few in number, small, and when the patient is still far from the menopause. This last condition is rare. Statistis show that fibromata are far less frequent in young subjecta It can be seen that it is only in very rare cases in whi conditions are favorable for enucleation of the tumor was out extirpation of the uterus, that the operation consideration would be the method of choice. The pe ation when undertaken is conducted like an ordinary iparotomy.-Gazette de Gynécologie.

Decrease of Population in France.—It appears that i a not alone the question of race suicide that is troubling sanitarians of France, but also the terrible increase death rate. According to The London Telegraph, Dr. L enthal, who is a member of the commission which is tigating the causes of the shrinkage in census ret not exaggerating when he says in a recent article "alcoholism alone is killing France." Tuberculosis, be tinues, which of all diseases is the most easily av raging in France with more violence than in any country in the world. Every year it kills more tic 000 victims, and contaminates more than half a more. Then typhoid, typhus, dysentery, scarlati other diseases and infectious maladies, which are d ing in England, Germany, Switzerland, Belgium, Es Sweden and Norway, the United States, and even m are, on the other hand, remaining at a very high en in France, some even displaying a marked tenden develop. Smallpox, which has nearly disappeart: “ every civilized land, continues to make thousands ei in France, and hecatombs in her colonies. Such is of Dr. Lowenthal's article, and it cannot be said th inclined to be unduly pessimistic.

Alcoholism in German Schools. How widespread consumption of alcoholic beverages throughout Gl is well shown in a recent paper by Dr. Goldfeld, va

recovered.

Broncholithiasis.-D. Braden Kyle reports a case of this unusual condition, his patient being a woman of thirty-eight years, who, for the five years before coming under observation, had had a hacking cough with a sensitive spot on the left side of the chest, in the second space slightly to the left of the parasternal line. Coughing came on in paroxysms, during which a lancinating pain was felt in the sore spot. There was no hæmoptysis and no dyspnoea, exNo tuberculosis could be cept at the coughing spells. made out. In one of the attacks a hard, irregularly formed, oblong body, about .5 x .8 cm. in size, and bony in appearance was expelled. The surface was uneven, with four small crests and one deep excavation. The analysis showed its composition to be calcium and magnesium phosphate, combined with a small quantity of calcium carbonate and organic matter, which are the most usual eleThe attacks of ments found in bronchial concretions. cough and the chest tenderness did not occur after the stone was expelled.-The Laryngoscope.

Abdominal Myomectomy.-V. Cocq declares that the treatment of uterine fibromata has given rise in the last fifteen years to many diverse opinions. At one time, conservative gynecologists thought that they had found in But the results of this electrotherapy a powerful aid. treatment were not what had been hoped for. Those at the present time who are advocates of the expectant treatment are in the minority. The greater number of gynecologists agree that it is better to operate when the conditions are good than to wait till they are changed, till the patient

a S

of alcoholism among the school children of Germa the author believes that the situation is serious mo be brought to the attention of the parents by addresses at meetings and by the distribution of $5 the evil effects of alcohol. The investigator officer of the public schools of Schöneberg. Berlin, and his examination included 967 children. A whom were in a boys' school and 497 in a gi Of these, 496, or 51.3 per cent., were accustomed from one to two glasses of beer daily, while 20 per cent., took spirits more or less frequently, ite beverage was malt beer, but all kinds of various kinds of spirits were taken, the sweet being preferred by the girls. Dr. Goldfeld was the teachers that the children addicted to the use were especially lazy, absent-minded and inclined Neither children nor parents heeded Dr. Golf ing.

Manufacture of Vodka in Russia.-Measure by the paternal forms of government sometimes curious results. According to London T-1 able scene was witnessed a few years ago, of Russia ordered that the private manufacture “ (the national drink) should cease, and that the should be taken over by the state and cond perance lines. The new state monopoly was 3. in a remarkable way. Priests attended at all *** shops by official command, and conducted specs The public houses were dedicated to God and 1fered that under the new régime drankens abolished and the spiritual welfare of the pe

MEDICAL RECORD.

THOMAS L. STEDMAN, A. M., M. D., EDITOR.

PUBLISHERS

WM. WOOD & CO., 51 FIFTH AVENUE.

New York, December 3, 1904.

THE SANITARY BACKSLIDING OF CUBA. THERE have been for some time persistent rumors of the reappearance of yellow fever in several of the Cuban towns, and three cases have been officially reported within the past month by the U. S. Public Health and Marine Hospital Service. These three cases were not imported from Mexico, but are said o have originated at Punta de Sal in Santiago Provnce. If this is true-and a despatch from Havana ays that Dr. Finlay, chief of the Cuban Board of Health, admits that at least one case originated on he island-it is a matter of grave importance. The isease cannot arise de novo, and if one case has riginated at Punta de Sal there must have been a revious case, and possibly, even probably, a series cases. This fact, taken with the known filthy ndition of Santiago and other towns in the eastn end of the island, is one to cause concern to this untry. According to the report of the U. S. argé d'Affaires in Cuba, the streets of Santiago e in such a condition as to be most favorable to breeding of disease germs, and particularly those yellow fever. It is stated that there is practically drainage, and that water is allowed to stand in streets for days at a time. The press of Havana firm these reports, one paper, the Discu1, stating that it is an undoubted fact that sanion in nearly all the towns of the island is at such w level that the public health is in danger. The er declares that this condition of affairs is a blot the republic and a shame to the Cuban people. 1 consequence of these reports, the State Dement at Washington has called the attention of Cuban Government to the necessity of rigid sanicontrol of the situation in the island. This acof our government finds warrant in the sanitary le of the "Platt Amendment," which provides "the Government of Cuba will execute and r as necessary extend the plans already devised, her plans to be mutually agreed upon, for the ation of the cities of the island, to the end that urrence of epidemic and infectious diseases may evented, thereby assuring protection to the peond commerce of Cuba, as well as to the come of the Southern ports of the United States he people residing therein."

-haps this reminder from Washington and the approach of the annual meeting of the Public Association in Havana will give the needed

- the Cuban health authorities, who are thor- capable but have to struggle against the tary traditions of Spanish officialdom.

Journal of the Association of Military Surgeons for October, his experience as operating surgeon at the Department Hospital at Iloilo during a year from May, 1900. In that time sixteen cases of liver abscess were seen, mostly accompanying or following amoebic dysentery. This series gave seven recoveries and nine deaths. Eight autopsies revealed conditions not discovered beforehand which rendered death certain. In some cases operation gave a measure of relief to symptoms, but could do no more. Considering the emaciated and weak condition of the patients, the tendency of the dysentery to recur, and of the suppurative process to spread, it may safely be assumed that without surgical procedures all the patients would have died. Not more than six entered hospital with a correct diagnosis, the condition being regarded as appendicitis, malaria, acute pleurisy, acute pneumonia, peritonitis, empyema, convalescence from typhoid fever, and delirium tremens with pain in the side. After the surgeons became more familiar with this common complication of amoebic dysentery and were on the lookout for it, the diagnosis was made more readily. The errors in diagnosis, and the total failure to recognize the disease early, account for the high rate of mortality. In the only two cases where a blood count was possible, no leucocytosis existed, but anæmia was present. In the majority of cases dysentery coexisted. In all the cases without dysentery, recovery took place. In all cases emaciation and debility existed, as the results of the dysentery, the unrecognized abscess, and the climate; and were important factors in determining the fatal issue. In thirty-two autopsies on dysentery cases, liver abscess was found in five. These so-called abscesses are not true abscesses, but rather areas of necrosis, and their contents are liver cells in all stages of degeneration and disintegration, free fat particles, and more or less blood corpuscles and serum. They do not contain pus. were found in eight cases, in some only when scrapings of the abscess wall were examined. In all cases with concomitant dysentery, amoeba were found in the stools.

Amœbæ

In diagnosis the previous history is of the utmost importance. With a history of dysentery of tropical or amoebic type, and an indefinite pain or sensitiveness over the liver on compressing the ribs on the right side, with chills or chilliness, and fever more or less similar in type to that of septic infection, liver abscess may be suspected whether or not the liver is enlarged. If with the above symptoms, dysentery coexists, abscess is almost certain. Aspiration may aid, but it is by no means certain, as many punctures may fail where subsequent operation discloses abscess. Finding the abscess is thus a good deal a matter of luck. It is, however, a good plan, just before operating, to try to locate the abscess by aspiration, as success gives a good guide, and in case of failure no harm is done.

The diagnosis once made, immediate operation is demanded. Whether bulging or not, the abscess should never be evacuated by the trocar and cannula, on account of the danger of infecting the serous cavities. No one can be sure whether adhesions exist or not; most likely they do not. Operation by in