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this without entering upon the matters of asepsis and antisepsis, the manner of caring for the child, the question of ether or chloroform or neither, all of which are left for future issues. Here is a skeleton upon which you can begin to hang your contributory criticisms and suggestions until we finally have a well-developt, fully-formu. lated scheme of action. Let us try to elucidate and reduce to exactness the familiar.

Cerebrospinal Meningitis.

In addition to the plague of typhoid fever with which the long-suffering inhabitants of this city have been afflicted, report is made of the outbreak of an epidemic of cerebrospinal fever or cerebrospinal meningitis, as it is indifferently termed, being identical with the so-called "spotted fever" of common parlance. Outbreaks have also been recorded in other sections of the country, notably where unsanitary conditions prevail, and hence a few words on the disorder will probably prove timely.

Cerebrospinal meningitis is a germdisease, as is proven by the unvarying presence in the exudates of the micrococcus lanceolatus, generally accepted as the causal agent. Still this has thus far shed very little light upon the therapeutics of the disorder, indications for treatment in accordance with this condition being exceedingly meager.

The disease seems to be ruled more by community predisposition than by the infection of the localities in which it is found, as may be demonstrated by investigation of minor points connected with the outbreaks. In other words, the residents of a certain neighborhood or locality are exposed to the same condition of residence, of climate, of alimentation, etc., and in some degree come to acquire certain similarities, which in this instance, end in a predisposition to a certain form of disease. This explanation of the fact of cerebrospinal meningitis occurring in epidemics seems the only plausible one, since the causal

microorganism is supposed to be constantly present in most soils.

The disease is very diverse in its manifestations, and is classt by modern writers into many types and subdivisions. Perhaps the most satisfactory grouping is that which classifies the types as the abortive, the fulminant, the petechial and the ordinary. The disease shows not only the differences in degree that appear in all infectious diseases, but also presents variations caused by the characteristic profound toxemia and by the principal condition of the acute exudative inflammation of the cerebrospinal meninges. The treatment follows lines as diverse, being influenced by the differing symptoms of each case, by the personal equation of the attendant practitioner, and by the prevailing fashion in medication, for these things do have their influence beyond a doubt.

The disease in certain localities and at certain times, has presented markt characteristics of depression, and naturally those treating cases with such symptoms have adopted a vigorous and supportive treatment. Again, the inflammatory processes involving the meninges have predominated and energetic depletory measures have been instituted to meet the conditions apparent. Still both these plans have in the aggregate proved unsatisfactory, and hence the body of the profession has adopted, as generally indicated, what may be styled a modified expectant plan, with energetic measures symptomatically as occasion arises.

The mortality of the disease is very high, ranging from 30 to 75 per cent. Hence comparisons instituted with a view of determining the value of a given form of treatment cannot be relied upon. Besides the element of the capricious nature of the disease and the different manner of its manifestations in different epidemics must also be taken into consideration, and will influence any conclusions drawn from a comparison of cases occurring in different localities, under different conditions, and in different epidemics. Even the cases so

near the type as to justify the classing as average each differ from the other in varying degree in accordance to the degree of the combination and degree of virulence of the two principal conditions existing pathologically.L

The statement has been made that the symptoms of the disease, from its very inception, were those of dissolution. This is exactly true in the fulminant type in which the patient, in his ordinary health on awaking from sleep or while at his usual daily work is struck down by the sudden onset of agonizing pain, passes rapidly into coma, and perishes in the course of a few hours. In this type, with its rapid course and the extensive lesions, all efforts of treatment are powerless, and all the resources of medicine can afford no means of combating the attack or of inducing a cure.

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A first requisite of treatment is that the patient should be placed in a dark room, and kept as quiet as possible. All noises, especially those of a recurrent and insistent character, must be strictly excluded. The diet should be as generous as possible, from the appearance of the initial symptoms. Milk, eggs, meat-juices and strong broths should be given at frequent intervals, day and night, so long as the digestive organs are not overtaxt. If food cannot be given by the mouth, nutritious enemas should be given. Pure water in so great quantities as possible should be given at frequent intervals, and the bowels should be maintained soluble.

A word must be said against the practice of bloodletting, at one time so generally practised in this disorder, and even yet occasionally advocated. The disease exerts a rapidly disintegrating effect upon the blood, and early and markt debility generally accompanies with a markt depression accentuating the susidence of the febrile attack, all strong contraindications to the use of the lancet. Even when the patient is most robust, the application of wet cups to the nape of the neck and along the spine, altho followed by temporary

relief of pain, have also occasionally been followed by alarming symptoms of depres sion, and should be used with great caution., If the condition of the circulation seems to indicate the abstraction of blood, this is best done by leeches to the temples or in the vicinity of the mastoid processes, the clinical history of the disease with its sequent depression being borne in mind. Dry cups may be used, as being unattended with the depressing effects noted, and also in many instances indueing relief of ex-treme pain.

In almost every case, alcohol is indicated at some stage, but its indiscriminate use has not been followed with good results. It is indicated when depression of the nervous system appears, no matter at what period of the attack. The character of the pulse should influence the amount given. If it becomes fuller, stronger and more regular, the administration of alcoholic stimulant should be continued. But if it increases in frequency, becoming excited and irregular, if the tongue grows dry and restlessness is augmented, it is possibly best to discontinue its use, or at least to decrease the amount given.

The direct application of cold to the head and spine is of use, the procedure being usually followed by amelioration of the symptoms. Systematic cold bathing is also of markt benefit if the temperature is very high. External heat should also be used, in order to combat the depression which is so sure to follow. This may be accomplisht by hot flannels, hot water bags, etc., placed next the patient, and this means should not be neglected even while the cold applications are made to the head and spinal column.

A dose of calomel at the beginning of the attack is sometimes of use, but further than this the mercurials seem to be contraindicated.VMercury in some form was long a favorite remedy in the disease, but the consensus of modern opinion is against it. The same is true of quinin, which can only be of benefit in small doses during convalescence for its general tonic effect.

The highest place in the therapy of the disease is conceded to opium in some of its forms. There seems to exist a remarkable tolerance for the drug during the course of cerebrospinal fever, and is to be employed at the earliest moment and in full doses, The indications for its use are the headache and pain in the back, the condition of spasm, the hyperesthesia, restlessness and sleeplessness. So large doses as one and two drams of laudanum, and 30 to 60 grains of the crude drug have been given with the effect of subduing the excitement and relieving the pain, but without producing somnolence or the other usual effects of the drug, and have in many cases been followed by recovery. The remedy is to be given for the effect, and the amount necessary to produce this effect must be administered.

If the symptoms indicate exudation, however, the usefulness of opium is greatly diminisht, and it must be given in more guarded doses. Its efficiency is greatest at the inception of the disease. Its use is even indicated, according to many authorities, in cases in which coma threatens, an exception to the general rules for administering narcotics, and many medical authorities of note claim that the drug is a powerful agent in obviating coma in cases not absolutely irrecoverable. If the patient vomits the drug or is in a condition in which it cannot be taken by the mouth, it may be given in enemas or by suppositories, or morphin may be given subcutaneously. A hypodermic of morphin night and morning, with the administration of suitable doses of the deodorized tincture of opium in the interval, is an ideal method of treatment, when the doses are cautiously regulated and the attendant symptoms of restlessness and jactitation are met with small doses of hyoscine hydrobromate.

If the case is of a mild type, and particularly in children, the addition of the bromids to the opium treatment, with a consequently smaller dose of the opium, is to be recommended. Thruout great caution must be exercised against the use of

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Treatment of Tuberculosis.

There is as yet a certain hopelessness in regard to the therapeutics of tuberculosis of the lungs in any save the incipient stages, that renders any discussion of treatment rather a thankless task, since the best that can be offered is mainly palliative and for the most part directed to the relief of symptoms. The condition of hemoptysis. has already been fully discusst in these columns, and it is not designed at present to enter into the surgery of tuberculous lesions.

Possibly more attention has been directed to the surgical treatment of tuberculosis of the lungs as advocated by Dr. Murphy at the latest meeting of the American Medical Association, than to anything else that has been promulgated in this field. Dr. Murphy's argument had all the freshness of a new discovery, and argument has waxed and waned pro and con upon it since, altho it is as yet too early for decision as to the value of the procedure. Briefly, Dr. Murphy's method amounted to a rest-treatment of the diseased tissue. He advocated causing the collapse of the affected lung by the introduction of gas into the cavity, throwing the burden of the respiratory function upon the other side." After the tubercles had reached the proper stage, in which they would not be affected by the action of the lung in breathing, the lung might again be inflated and put into use, without fear of extending the tuberculous process. Thus far the profession seems to have rendered a "Scotch verdict " as to its usefulness, and many objections have been brought forward, such as the possibility of the development of the pneumonia in the lung remaining in use while

the other was still in "commission," the possibility of renewed use of the disused lung causing renewed activity in the old lesions, etc.

Thus far the hopes aroused by the announced discoveries of tubercle-serum have not been realized, altho reason would seem to indicate that in this line the highest development of preventive and curative. medicine must eventually come. There are the usual number of enthusiastic advocates of each successive discovery and the usual quota of those opposing, some, it is true of those who on general principles oppose everything new, but more of the rank and file of the profession, those who are cautious in their methods, who do not run after the latest thing, and who prefer to do the good possible with tried methods rather than experiment with the unknown.

The consensus of medical opinion as to the treatment of phthisis seems to remain steadily in favor of creasote, benzosol and cinnamic acid as the most effective medicinal agents, when used with general measures tending to build up nutrition, and supply the excessive waste of the system. These are administered either by the stomach in capsules combined with codliver oil and gentian or some other tonic agent, or are used as in inhalants, to secure, so near as possible, direct contact with the diseased tissues. There is the usual array of statistics of recovery under each drug, but even with these the attitude of the professional mind seems that of incertitude. Of all the measures, however, the use of creasote or some of its derivatives is thus far the most approved.

The chief dependence, however, since the tubercle-bacillus has been demonstrated to be practically indestructible in the human system, must lie in methods of prophylaxis and in measures directed to rendering the germ latent. This is also indicated from the fact that many cases of spontaneous cure have been reported, due often to the encapsuling of the tubercle in fibrous tissue, etc. Meanwhile research in medical lines is being stimulated in the

direction of the determining of the agent best adapted to induce this process in diseased lung-tissue. The highest claims thus far have been made for the intravenous injection of cinnamic acid, the active principle of Peruvian balsam. The injection is generally made into the median basilic vein, a sterilized, aqueous 5 per cent. solution of sodium cinnamate being used.

Climatic treatment is, however, the chief line that engages medical thought at present, and there are probably more advocates of the so-called rational method, of not so much entire change of climate as the using of all means to keep the patient night and day in the open air, encouraging free oxygenating of the blood, and directing every effort toward physical development. This treatment has been pursued as the main plan of the cottage sanitariums establisht in the Adirondack region of New York, and thus far better success has been reported from these than from any other collated series of cases. The fact is admitted that the constant supervision of the patient's life and the strict regulation of his diet are factors of no little importance in bringing about the happy results noted. There is little in these systems that cannot be reproduced within private practice, provided the physician has sufficiently the confidence of his patient to ensure the strict adherence to the course prescribed. The treatment is so diagrammatically opposed to the usual plan of keeping a phthisical patient confined to close rooms that the fear on the part of the laity that the consumptive will "take cold" must be met and combated, and this is a factor of no little importance. To successfully carry out the treatment the active co-operation of the patient and his friends is necessary, since variation in the line adopted may have serious consequences.

Unlimited fresh air and sunshine, with scientific exercise directed toward improving the lung function, and full and generous diet are the essentials of the treatment. The mode must be adapted to each individual, taking into consideration the gen

eral condition of the patient and the stage of the disease, the febrile 'manifestations,

etc.

Treatment of Measles.

In measles, as in all of the exanthemata, attention must be paid first to the hygienic management of the patient and the surroundings. In the uncomplicated cases of only ordinary severity very little aid from drugs will be required.

The first requirement is the strict confining of the patient to bed until the final disappearance of the rash, even to the last yellowish-red stains which succeed the active stage. There should be every precaution to prevent the taking of cold, altho bedclothing merely sufficient for warmth should be used. Too great heat and too much weight of clothing will contribute much to increase the discomfort already caused by the disease.

The chamber selected for the sick-room should be, if possible, isolated, large and airy, provided with screens in order to prevent drafts during ventilation. The proper temperature is 65° to 68°. The light should be subdued, as the eye sympare always of consequence, and, whenever this is at all possible, the patient's back should be toward the source of light. Altho it is not so absolutely necessary as in scarlet fever to strip the room of all draperies, yet it is well to dispense with all unnecessary hangings.

After convalescence is even well establisht, it is well, for five or six days, at least, to keep the patient confined to the room, and even after this period he should not be permitted to go out of doors until at least three weeks from the beginning of the attack; and it is at least an open question whether it is not best to keep the room for this length of time. Measles is one of the diseases in which over-caution is better than too great laxity; this because, next to typhoid fever, it is the most liable to relapse of all the exanthemata. There have been a number of authentic cases of relapse or recurrence, both attacks

sometimes running their course within four or five weeks.

Careful attention must be paid to the diet, the object being to secure sufficient nourishment without overloading the alimentary canal, or overworking the digestive powers, enfeebled by the general catarrhal condition of the mucous membrane. With this purpose it is well to give food at more frequent intervals, but in smaller amounts than is usual. When milk forms the staple food, it is well to use half cream with admixture of a little limewater in order to prevent rapid coagulation and the formation of large, tough curds in the stomach. Occasionally it is impossible for the child to retain milk, and in such cases raw beef-juice and veal or chicken broths will prove the best substitutes. The liquid diet should always be enjoined. Do not give lemonade nor anything save pure, cool-not cold, water, and give this in a small glass, so that the patient can drain it if desired.

Bathing should be an important part of the treatment, the entire body being sponged off at least once daily, washing a little of the surface at a time and drying this carefully before proceeding to another part.

The medical treatment is very simple. In the early stages potassium citrate is useful to lower the temperature and relieve the catarrhal inflammation of the mucous membranes. If there is a croupy tendency, syrup of ipecac should be given. Later ammonium chlorid and quinin come into play. Sweet spirits of niter or spirit of Mindererus are often of great service. During convalescence iron and codliver oil should be given.

The eyelids should be washed four times daily with hot water, and a few drops of a weak solution of boracic acid should be applied to the conjunctiva. The nares and pharynx should also be sprayed with dilute Dobell's solution.

Headache should be treated first by unloading the bowels, altho an active purge should never be given on account of the

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