of this, each portion of the body receives a more perfect supply of blood and feels rejuvenated. Following this stage of exhilaration a third comes on in which the blueness and depression of the first stage recur in an exaggerated degree, but this condition does not ensue unless the person remains too long in the water. If he leaves the bath while in the acme of his exhilaration, the stimulus may remain with him throughout the rest of the day."

The reason for the occurrence of this train of symptoms, is not far to seek. The chilliness of the first stage shows that the great abstraction of heat is lowering the bodily temperature, the centres for calorification in the body not manufacturing all the heat that is needed for the preservation of the normal temperature. At first the cold drives the blood hurrying into the warm recesses of the body, leaving the surface cold; but in a few moments the system is aroused to the recognition of the fact that it must increase its exertions in the propulsion of blood and the manufacture of heat, and so with an effort it puts forth all its power, picks up each corpuscle that is hiding from the cold in the internal organs, and, after imbuing it with warmth obtained by increased heat-production in the sources of heat-manufacture, forces it out to the surface of the body along with its fellows, which are driven to all parts of the system. This is not a mere figurative way of putting the matter, for cold always contracts blood-vessels and reflexly stimulates the vital centres to increased activity.

The cold bath, therefore, has a physiological action far more important than the withdrawal of heat, this being a minor and side issue, and it really puts the system in the best trim to resist disease. Only when used for a protracted period of time in such a way that it abstracts more heat than the body can make, does it really reduce the temperature of the entire body.

My views in regard to these questions may therefore be summed up as follows:

First: Moderate fever has been proved to be in itself harmless. Hyperpyrexia is of itself harmful.

Second: Moderate fever has a useful function to perform in the body in the presence of an infection.

Third: Cold baths do good, not by the mere abstraction of heat, but by increasing metabolism and the rapidity of all vital pro

cesses.

Fourth: The use of antipyretic drugs is

contra-indicated in all infectious diseases. Five years ago, when their use was far more popular than it is to-day, and before we knew as much of their effects and the development of immunity by antitoxin, I said in an essay on "Fever and Antiseptics" to which was awarded the Boylston Prize of Harvard University:

Anti

"While it is true that antipyrin may be employed in any disease associated with high temperature, such as typhoid fever, pneumonia, or erysipelas, it must not be forgotten that but one object is gained by its use. Antipyrin, even though its influence may be most favorable in a given case, still accomplishes nothing in the way of cure. pyrin only governs the heat processes while the disease plows its way onward to recovery or death; although it may, by quieting restlessness due to the fever or to the nervous disorder produced by the disease, render the pathway to recovery more easy, but no shorter than if it were not employed.

"Many physicians have looked and still look upon antipyretic treatment as curative in its effects, but nothing can be more distant from the truth. It should be distinctly understood and taught everywhere that these drugs belong to a peculiar class; a class of drugs to which we gladly turn when told 'to treat the symptoms as they arise;' a class of drugs which are to be used solely for the relief of the symptoms, and not for the cure of the disease."

These views I still hold, and I think that those best qualified to judge will give them their endorsement.

CHLOROSAL IN THE TREATMENT OF DIARRHEA.

The Revue Illustree de Polytechnique Médicale for October 31 remarks that this is the name of a new drug which is a salicylic derivative of chlorophenol. Two isomeric combinations are known, orthochlorosalol and parachlorosalol. These are crystalline substances, white, insoluble in water, and soluble in alcohol and ether. The former has a rather strong odor, while the latter is tasteless and odorless. Girard administers it with success in amounts of from thirty to sixty grains a day in catarrhal affections of the urinary tract and in cases of diarrhea. It may also be used to powder certain kinds of wounds, as it has the advantage of not producing any local irritation.-New York Medical Journal, Dec. 14, 1895.1

The Editor is glad to announce that arrangements have been completed and are now in effect which will provide the Correspondence Columns of the GAZETTE with interesting foreign letters from the great medical centres. The gentlemen who have consented to keep the readers of the GAZETTE posted as to medical matters in London, Paris, Manchester, Berlin, Vienna, Edinburgh, and other cities, are well known as able contributors to current medical literature, and occupy positions in the profession which put them in touch with the facts which are most interesting to their professional brethren in America and elsewhere.

By this means, added to the Original Articles, the Editorials, the Notes on Therapeutic Progress, the Reviews, and the Notes and Queries, subscribers to the THERAPEUTIC GAZETTE have the latest and best medical information brought before them every month in a form suitable for practical application.

THE TREATMENT OF GALL-STONES.

In the January issue of the THERAPEUTIC GAZETTE we spoke of the treatment of gallstones from the standpoint of preventive med

sider in this number the treatment of the patient suffering acutely from their presence. Before doing so, however, it is well to remember that the pain felt in the right hypochondrium may be due to the presence of a renal and not an hepatic calculus, and that the distribution and character of the pain may in some instances so closely resemble hepatic trouble as to cause a faulty diagnosis. Again, it is well to preface a consideration of the treatment of gall-stone colic by the recollection that the opening of the common duct into the intestine is guarded by a sphincterlike arrangement which prevents the ingress of the intestinal contents, and, in the case of a stone being passed, tends to prevent its slipping out into the bowel. Again, it is not to be forgotten that there is usually present not only a markedly catarrhal state of the biliary mucous membrane, but often patches of ulceration, from which general infection or perforation may ensue. Finally, the presence of severe pain and tympanites following upon the constipation, so often present in these cases, renders any movement of the bowel difficult or impossible.

The therapeutic indications are, therefore: the relaxation of the sphincter which is in spasm and guards the opening through which the stone must pass; to aid in the expulsion of the stone by the removal of mucus and the congestion in the inflamed mucous membrane; and to relieve tympanites and constipation, not to speak of the pain.

We have already urged elsewhere the free use of spirit of chloroform for the relief of abdominal pain and for relaxing muscular fibres which may be gripping the stone, and we wish to emphasize the importance of this use of this preparation by pointing out that it tends to stop vomiting, relieves tympanites, and acts as an intestinal antiseptic. Along with the chloroform spirit may be given full doses of tincture of belladonna by the mouth, or atropine hypodermically, and the patient should be placed in as hot a bath as he can stand until a large injection has been prepared for the purpose of washing out the rectum and colon. The question as to whether morphine should be used, hypodermically or by the mouth, in such cases, will, we think, be usually answered in the affirmative by the practitioner of experience, on the ground that it is necessary for the relief of the excessive pain and for the purpose of relaxing spasm. On the other hand, it has been pointed out by experienced physicians that very full

doses of morphine may cause such complete relaxation that, while the pain is removed, the stone is not expelled, but remains in situ, ready to cause ulceration, obstruction, and another attack of colic. Moderate doses of opium or morphine are, therefore, to be counseled. Indeed, it is asserted that it is only to be given when the patient is exhausted, and if used then, to be given in large enough single dose to be unfailingly effective. Probably the best plan for relieving the pain is to use chloroform or ether by inhalation to the point of primary anesthesia, or, in other words, just enough to take the edge off the pain without stopping the expulsive efforts,a process daily resorted to in cases of parturition.

The question as to whether emetics are to be used in these cases, in order to aid in producing muscular relaxation which will result in the release of the stone, is to be answered in the negative, since the vomiting may cause rupture of the gall-bladder if this viscus is distended by stones or bile.

The sudden relief of pain points to the escape of the stone into the intestine, and a dose of castor oil should be given at once to sweep it out for examination. If the pain gradually declines, it points rather to a subsidence of effort without expulsion, and as soon as the patient recovers the question of operative interference is to be seriously considered, particularly if the attacks have been frequent and the patient's health is suffering.

That the question of operation for gallstone is not as serious as many suppose, is shown by the fact that about ninety-five per cent. of cholecystotomies for gall-stone recover; Mayo Robson states that in his hands it is even better than this, for of forty-four cases all got well. On the other hand, the operation is undeniably a difficult one, may be followed by more or less general peritoneal inflammation, and is often found to be more hazardous than at first supposed by reason of the presence of large inflammatory exudates due to chronic inflammation about the gall-bladder or ducts.

In conclusion, it may not be out of place to append Mr. Robson's conclusions as to the indications for surgical interference in gallstone troubles, as they appeared in the Clinical Journal:

1. Repeated attacks of biliary colic which, not yielding to medical treatment, are wearing out the patient's strength.

2. Suppuration in the neighborhood of the gall-bladder, as in empyema of the gall-blad

der, or in abscess of the liver, associated with gall-stones.

3. Dropsy of the gall-bladder.

4. Obstructive jaundice where there is reason to think that the common duct is occluded by gall-stones.

5. Acute peritonitis starting in the region of the gall-bladder, where the previous history of the patient is suggestive of gall-stones.

6. Intestinal obstruction due to occlusion by a large biliary concretion.

THE USE OF OXYGEN GAS DURING SURGICAL ANESTHESIA.

The two conditions which, while not alarming, are, nevertheless, annoying to the surgeon, which ensue when ether is administered as an anesthetic, are cyanosis and nausea, and vomiting when the patient regains consciousness. In some instances this nausea and vomiting are so intense as to cause the patient far more suffering and physical injury than the operation itself, and any therapeutic method which can put aside this disagreeable concomitant or after-symptom will be highly valued by practical physicians. While the administration of oxygen during or after anesthesia produced by ether and chloroform is by no means a new therapeutic invention, it has recently been prominently brought forward, first, by the interesting correspondence of Dr. Theophilus Parvin, in which he has described his experiences during a visit to Landau's clinic; and, second, by the paper of Dr. C. B. Cole in the New York Medical Record of October 12, 1895. Dr. Parvin tells us, in a personal interview, that the practical results following the administration of oxygen gas in the convalescence from operations was to him most impressive of its value; that the patients recovered consciousness more speedily than under ordinary circumstances, and that to many if not all of them subsequent nausea and vomiting were unknown. In the paper of Dr. Cole, which he publishes as somewhat of a preliminary communication, an interesting account is given of several cases in which the administration of oxygen and ether in the mask acted exceedingly well in preventing the cyanosis and interference with respiration so frequently seen during anesthetization. We can, therefore, bring the matter before the readers of the GAZETTE with some confidence that the advantages which would theoretically follow the administration of this

gas during anesthesia are found to be present in practical experience, and the harmlessness of the method, combined with its efficiency, seems to us to recommend it highly to those who have the best opportunities for testing its value.

THE ERUPTIONS PRODUCED BY DRUGS.

Although every dermatologist recognizes the frequency with which various forms of skin-eruptions appear after the administration of many medicines, it is probably true that the average practitioner does not pay sufficient attention to this possibility, and is therefore misled in some cases into making a diagnosis of one of the exanthemata or of deciding that the eruption is a typical disease of the skin. It is impossible, in the short space which can be devoted to a leading article, to go over in detail all of the drugs capable of producing such untoward effects. On considering the most prominent of them, it can be laid down as a safe rule that a diagnosis of a skin disease ought never to be made with positiveness until the possibility of the lesion being produced by a drug has been entirely put aside. Only recently one of the most prominent dermatologists in this country said to the writer that it was surprising how many cases were sent to him by physicians who were not specialists in diseases of the skin, on the supposition that the individual was suffering from some true skin-disease, when, in reality, the withdrawal of the medicine which the patient was taking for some other complaint was speedily followed by complete recovery. Of all the drugs which may produce lesions in the skin which closely resemble forms of true skin-disease, iodide of potassium ranks first.

bullous eruptions, and

Urticarial wheals,

even eczematous catches may follow its administration, while in other cases an intense pruritus develops, which is thought to be due, perhaps, to the gout from which the patient is suffering rather than to the drug. Singularly enough, quinine is another drug which produces eruptions more frequently than is generally recognized, perhaps the most common form of eruption being urticaria, or in its place an intense erythema. The eruption of quinine and belladonna may so closely resemble that of scarlet fever as to make a diagnosis between the two conditions very difficult, particularly as the belladonna is very apt to cause a slight rise of temperature. Antipyrin may also produce such a rash, though it more

commonly resembles the eruption of measles; and salicylic acid may, as may also iodide of potassium, cause localized edema; while arsenic causes pigmentation of the skin. The subsequent course of the case, and the fact that these eruptions are generally uncomplicated by other symptoms, will do much towards enabling the physician to guard himself against deception, provided he will but remember the possibility of skin-changes under the use of remedies.

TREATMENT OF SURGICAL TUBERCULOSIS BY MEANS OF IODOFORM INJECTIONS.

Since Mikulicz prominently brought before the profession the anti-tubercular action of iodoform when brought in direct contact with diseased foci, the literature of surgery has furnished countless reports corroborating the findings of this surgeon and showing results so satisfactory that in recent years the percentage of arthrectomies, of excisions and of formal major operations undertaken for the relief of surgical tuberculosis in bones and joints has markedly diminished.

The iodoform treatment-that is, local injections of iodoform-containing fluids into tuberculous tissues-has in the main been used only in exceptional cases, and not as a protracted routine treatment. Indeed, the majority of all reports are open to the objection that a sufficient number of cases has not been observed by individual operators, or that the treatment has not been continued through a sufficiently long time, or, still more important, that the ultimate results are not recorded.

Wieland's records of the results obtained in the Children's Hospital at Basle are, therefore, of more than usual value, since he has been employing this treatment as his routine method since 1891, has observed many of the patients for a number of years, and in a fair percentage of his cases is able to report the ultimate results (Deutsche Zeitschrift für Chirurgie, bd. xli, heft 4 and 5). During this time there were thus treated twenty-one cases of cold abscess, including many psoas abscesses; of these, sixteen were definitely healed, four were improved, and one showed no improvement. Of twelve cases of joint tuberculosis treated by iodoform injections, nine were cured and three were improved. Of twentyeight cases of surgical tuberculosis first treated operatively-i. e., by incision and curetting -and afterwards by iodoform injections,

twenty-five were cured, two improved, and one died; of these last cases, together with affections of the larger joints, four were paraarticular abscesses, six diseases of the ankle, eight spina-ventosa, and ten multiple localized tuberculosis. The total number treated by iodoform injections was seventy, of which fifty four (that is, seventy-seven per cent.) were discharged as improved or cured; the subsequent history of thirty-eight of these was obtained-thirty-four having been discharged as cured, and four as improved; of the thirty-four cured cases, twenty-six remained definitely well, two suffered from local recurrence, five died of tuberculous disease developing in other parts of the body, one died of an unknown affection; in three of the four cases discharged as improved there was local recurrence within a year.

These results, especially when compared with those commonly accepted as satisfactory before the inauguration of iodoform treatment, are certainly encouraging.

The functional results of cure were best shown in the cases of psoas abscess following spondylitis. Pain, contractures and limping vanished entirely, and the vertebral caries appeared to be checked. This latter effect was probably not entirely due to the iodoform treatment, since, together with this, the customary orthopedic appliances were usedthat is, apparatus was applied by means of which extension and fixation were secured.

The functional results of the treatment of joint tuberculosis were not so satisfactory, though they compared well with those obtained by more radical procedures.

Wieland prefers an injection of ten-percent. iodoform emulsion in glycerin, both ingredients being thoroughly sterile. In the case of cold abscess the needle of the aspirator was driven in, the contents of the abscess evacuated, the sac thoroughly washed out with a four-per-cent. boric-acid solution, and from half an ounce to an ounce of the iodoform emulsion injected in. In case the abscess filled, this operation was repeated. Even if after a third or fourth puncture and injection the abscess filled, the treatment was continued. After this treatment the parts must be kept absolutely at rest, and over the abscess should be placed a pressure bandage, preferably of flannel. If the puncture is treated with antiseptic precautions, the formation of a fistula is not to be feared. The avoidance of this requires that the first dressing should not be left in place too long.

Mixed infection makes the ultimate cure decidedly more difficult.

When after repeated punctures and injections the abscesses refused to heal, they were opened, curetted, treated with iodoform emulsion, and closed. In cases of joint tuberculosis without abscess, intra-articular injections of iodoform were made. Where there was caries of bone or joint, with fistula-formation, the conditions commonly present in hospital cases, necrotic tissues were removed by partial resections or curettings, after which the iodoform treatment was instituted, the injections being driven either directly into the granulating wound, into fistulæ, or into surrounding tissues. In the severe cases of tuberculosis of the ankle and wrist, with multiple fistula, the results from the iodoform treatment were often surprisingly satisfactory.

As to the toxic effects, there is often, following the injection, a sudden elevation of temperature lasting one or two days, with hurried heart-action and sometimes profound systemic depression, headache, and vomiting. Occasionally children show urticarial eruption. If the fever lasts more than two or three days, the patient becomes profoundly depressed and is often delirious. Exceptionally, marked symptoms of intoxication develop, one such case is reported by Wieland, the pulse reaching 180, and delirium supervening, with suppression of urine. In four cases there was marked irritation of the kidneys, apparently not dependent upon the amount of iodoform employed; in two of these there seemed to be a development of acute primary nephritis, in the other two an exacerbation of the old disease.

Wieland states that as a result of his conservative treatment of surgical tuberculosis he is convinced that iodoform therapy, aided by orthopedic appliances and by minor operative procedures and careful attention to the general systemic condition of the patient, gives good results in children. This is particularly important, since the major operative procedures at this period of life are nearly always followed by great disability.

The disadvantage incident to iodoform lies in the length of time required for treatment, many of the cases lasting for years.

Wieland's paper is reinforced by careful case reports. Perhaps its special function and one of main importance is to call attention to the fact that the iodoform treatment of surgical tuberculosis requires more time and patience and as much skill and care as