ORTHOPEDIC NOTES. CA In the treatment of the second class of cases, or those of mechanical origin, the most important procedure is the accurate adjustment of an appropriate mechanical support, or such other mechanical measures as will remove or overcome the mechanical cause. A few of these cases are thus susceptible of absolute cure. Many others can be greatly relieved and improved; and there are but few in which the am aware that this is giving a prognosis much more favorable than is usually admitted for cases of lateral curvature; such results, however, can be obtained, though only by diligence and perseverance and constant attention. The mere (Continued from December number.) ASES of lateral curvature having a central origin are by far the most numerous; they are due to some occult fault in the nerve-progress of the deformity cannot be arrested. I tract, which causes a failure of some of the normal nervous influences to reach certain portions of the spinal and thoracic systems of muscles. Very nearly all the cases starting with a distortion in the dorsal region as the primary curve have this origin. Secondary and compensatory curves in the cervical and lumbar regions soon follow. The resulting deformity seems capable of progressing to almost every conceivable extent, and is almost universally accompanied with some rotation of the vertebræ. The different points and different degrees of deformity, and the different relative amount of rotation will depend upon, and will be easily explained by, the different extent to which certain sets and different portions of the complicated system of muscles that control the motions of the spinal column are affected or involved. The curvatures of mechanical origin have most frequently the primary curve in the lumbar region, and are usually unattended with rotation of the vertebræ. The simple classification here suggested will enable us to clear away much of the confusion and conflict of opinion that has prevailed in regard to the treatment of lateral curvature. Cases of the first class, those of central origin, can be best treated by gymnastic exercises, carefully arranged and regulated so as to be adapted to the condition of each patient; but some appropriate mechanical support will generally be found to be an indispensable adjunct, and the best possible hygienic influences must be provided. The best results will not be attained unless all these measures are skilfully and resolutely persevered in. By these means a practical cure is nearly always obtainable if the patient is early treated and is yet within the growing period of life. A complete arrest of the disease, with some diminution of the deformity, can be confidently expected between the twentieth and twenty-fifth years, and a like result is sometimes obtainable up to thirty-five or forty years of age, or even later. B A RC CHABOLER FIG. 8. application of ever so excellent a form of mechanical support and an occasional looking after it, will not do. Every mechanical support must be incessantly watched and continually kept up to its work. So, also, with any system of gymnastic exercise; it must be resolutely and efficiently carried out, and from time to time modified as the indications change. If aught less than this is done, dismal failure will continue to be the usual result of any and every kind of treatment for lateral curvature. Many ingenious methods have been devised by orthopedic surgeons to provide lateral curvature patients with appropriate gymnastics. These exercises should be conducted in connection with an improved position of the spinal column. Barwell's sloping seat is very simple a sort of "rack" which can be used so gently | For a similar class of cases, Fig. 11 repreas to give but little pain, but so effectively as to produce very favorable changes in many cases too feeble for any method of suspension. Stretching in the horizontal position provokes muscular contractions, and thus becomes really a valuable exercise to the spinal muscles, and if well arranged and regulated, can often be practiced without causing much fatigue. sents a very ingenious and useful machine, capable of innumerable niceties of adjustment. The patient sits upon the seat E, with the head supported on the rest A, the sides and back supported with perfect comfort and exactness by the movable pads C G and D, which can be almost infinitely adjusted to suit each individual case and each individual peculiarity. [To be continued.] COMMERCIAL NEWS. TREATMENT OF REMITTENT FEVER. On page 14 of this issue of THE MEDICAL BULLETIN, Dr. W. R. D. Blackwood, Neurologist Presbyterian Hospital, says, "The dietetic treatment of remittent fever is important. The food must be nutritious, yet digestible, and here the Tartarian Koumiss made by Mr. McKelway, of this city, fills admirably the indication, it being at once easily digested, gently stimulating from its carbonated character, and owning all the food value of good milk. Singularly those who dislike pure milk can take and relish the koumiss. It is invaluable in gastritis and wasting disease." This preparation of milk is also valuable in dyspepsia and debility following acute, or accompanying chronic diseases. It is agreeable and refreshing, and its use has been attended with remarkable success in allaying vomiting and gastralgia, and in restoring the process of nutrition. See advertisement of Mr. McKelway, on page 16. COCA AND COCAINE. PURE WATER. The Submerged Filter was awarded a bronze medal, the first award for merit, at the American Institute Fair in New York City last week; and from our personal experience with one we have, we thing it well deserves the compliment. Pure water is possibly the first requisite to the maintenance of perfect health, and since this filter is constructed on scientific principles, we bespeak for it an enthusiastic reception by the profession. See their advertisement on page 19. HYDRASTIS. "No remedy for physicians' use has been received with such universal approval." We quote the above from a well known medical writer, and would add that to the late William S. Merrell belongs the "largest share of credit for the introduction of Hydrastis preparations." It is claimed that these preparations stand preeminent to day as the most valuable exponents of our vegetable materia medica, applicable as they are to the treatment of all irritable, inflammatory, and ulcerative conditions of the various mucous membranes. The William S. Merrill Chemical Company have been experimenting with the drug for nearly half a century, and have produced a series of Hydrastis combinations representing all the active principles of the drug. They are the largest consumers of it in the world. Their advertisement will be found on colored insert. CANTON CHAIR. M. Bignon, Professor in the Lima (Peru) School of Pharmacy, says, "In fresh or recently dried coca leaves that have undergone no fermentation, there exist only one inodorous, crystallizable alkaloid, cocaine. Coca leaves dried in damp weather, or pressed into sacks before completely dried, undergo a fermentation that destroys the cocaine. The fresh leaves, or leaves freshly dried in the open air in fine weather, with frequent turning, and sheltered Dr. George B. Swayze, 1828 Columbia from moisture and dew, yield easily eight Avenue, Philadelphia, says, "The Canton grains per kilogram, and the fine sorts can give Chair embraces in itself all the best thought ten grammes and upward in exceptional cases and devices, all the essential conveniences and and on the spot where they are grown. The excellencies of all the chairs which have preemployment of coca by the Indians has been ceded it, and goes beyond them all in ease and badly observed. The Indian never chews coca grace of combination. At the same time it is alone; he mixes it with lime and ash, that is to the handsomest chair before the profession-say, with strong bases that isolate the cocaine." one that sensitive, nervous women do not shrink Having in view the cautions implied in this from-one which I would not exchange for any article of Professor Bignon, the Mutual Chemi- other. No little kink has been forgotten or cal Company have arranged to procure fresh overlooked in its construction-even to the jawsun-dried coca leaves for use in their "Phos- teeth fastenings of the shafts of the stirrups, phated Coca-Malt," and by combining them which secure any necessary or desired elevation with the phosphites of lime and soda, have and separation of the feet; to the automatic play produced a combination of unusual efficacy, of the curved foot rest of the stirrup to preserve containing with other valuable properties, all ease for the foot and ankle; to the lowering of the advantages of the aboriginal mixture of the seat softly from the patient." A cut of the coca and ashes. See their advertisement on chair appears in their advertisement, on page colored insert. 26. BY WALTER HAY, M.D., LL.D., CHICAGO MEDI- been exudations in the perivascular veins and CAL COLLEGE HOSPITAL. Professor of Nervous and Mental Diseases, and of Medical G Jurisprudence. [Reported by WILLIAM WHITFord.] ENTLEMEN: I desire to call your attention to the prognosis of epilepsy depending upon anatomical changes in the brain. Where epilepsy has existed for several years, it is almost necessarily hopeless. We sometimes find cases in which we detect an obvious traumatic cause-injury to the skull or brain--and we hope by the removal of that cause to remove the results. Where injuries are of comparatively recent occurrence, or where the epileptic state has existed for a short time only, we may hope to effect a cure by the removal of the traumatic lesion. I have in my recollection three cases of epilepsy that were undoubtedly traumatic in character. First case was a lady who had been kicked in the malar protuberance by a horse, when about fifteen years of age. There was considerable depression. The kick had been received only a few months before epilepsy began to develop itself. The case came under my observation at St. Joseph's Hospital, and at the request of one of my old colleagues (Pro fessor Gunn), and after consultation with the physician in attendance, I urged the operation of trephining. Both were unwilling-Dr. Gunn claiming that he had been disappointed so frequently in attaining good results. The opera pons. The next case was a lady about eighteen or nineteen years of age, who, in the act of repairing a cistern, let a step ladder fall upon her, striking her upon the left side of the head, about three quarters of an inch to the left of the sagittal suture. Epilepsy developed within three months, and persisted about twelve weeks, up to the time I saw the case. At our consultation the attending physician said that he had found a scalp wound, bleeding freely; he had closed it with sutures, and the patient did very well. I felt confident that there had been a fracture (but as far as palpation indicated, there was no perceptible depression). I again urged trephining, but the two surgeons were unwilling to perform the operation, and, although they afterwards consented, the physician in attendance insisted that there was no fracture. On making an incision and removing the periosteum, I found an exceedingly slight depression. It was, perhaps, of a diameter of threequarters of an inch, saucer shaped. It presented the appearance as if the head of a hammer had been pressed slightly down upon the bone. In performing the operation one of the surgeons bored until he was tired, and wondered if he was ever going to get through that bone. He finally got through it after boring half of an inch. The plug removed on one side was a little more than an inch deep, and upon the other not much more than a quarter of an inch, but across the upper face of the plug (after washing) there was a distinct bare line of fracture which resembled a hair. The fracture had been sufficient, however, combined with the violence inflicted, to produce inflammation, with a thickening of the bone and pressure, which had developed a counter-pressure upon the medulla and pons against the basilar plate of the occipital bone. The results of pressure were developed upon the convulsive centres of the brain; and we were very much gratified at the sudden arrest of the epileptic paroxysms. The patient did not return. Another case which I examined, and of which I kept careful notes, was thirty-three years of age, who had epilepsy from boyhood. The exact number of years could not be ascertained. However, he had been a persistent epileptic; no history of traumatism could be learned by questioning the man himself or his relatives; and his physician, who had known and attended him for twenty-five years, knew nothing of any injury. In placing my hand over his head, I found behind the mastoid process a large hole into which my thumb slipped very easily. I urged trephining. We made an incision, and learned then, for the first time, that he had been kicked by a horse when about three years of age. A doctor had sewed up the wound, put pieces of plaster on it, and the boy apparently did well. In this case there had been a fragment of bone two and one-half inches long by three-quarters of an inch wide at its broader end, and one-quarter of an inch at its smaller end, which had been driven down edgewise into the brain, and had become adherent to the new bone. The periosteum had not been deposited, so that that fragment of bone followed down with its long edge projecting into the structure of the brain. About a pint of fluid was evacuated, and after four hours' boring we got through that piece of bone (patient being under the influence of chloroform all the time). Four days after the operation I saw the patient on a balcony watching a procession; but the epileptic attacks occurred as before, and continued. There was no intermission whatever. The fact is that the anatomical changes, which I have frequently mentioned, as a basis, had become thoroughly organized in the medulla and pons, and, of course, were permanent, although the original cause was removed. Whenever you have a case of epilepsy, and can trace it directly to some traumatic cause, it is good practice to remove the source of irritation; but be careful also about encouraging your patient as regards a favorable termination after the removal of such a cause. MELANCHOLIA; MALIGNANT DISEASE OF THE LEFT LOBE OF THE LIVER. BY WILLIAM PEPPER, M.D., LL.D., Provost of and Professor of Theory and Practice of Medicine and of Clinical Medicine in the University of Pennsylvania. DELIVERED AT THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA. G [Reported for THE BULLETIN by WM. H. MORRISON, M.D.] ENTLEMEN: This case is an illustration of the form of mental trouble of which you will doubtless see many cases in practice, and which will prove very troublesome both to you and to the patient. This woman, aged forty-three years, tells us that she is a married woman, the mother of three children. She is happily married, and has had no domestic trouble and no cause for mental worry or strain. There is, however, in her family a predisposition to nervous disturbance. At the age of thirty-five her father began to manifest spells of melancholia, coming on suddenly, lasting for a number of months, and then disappearing suddenly. These recurred every year. He died at the age of sixty-five in one of the spells. Two of her father's brothers committed suicide. Her mother was always a cheerful woman. Her parents had eighteen children, nine of whom are living, but she is the only one who has manifested any symptoms of mental disturbance. There is no history of mental trouble in former generations. Twenty months ago she was suddenly seized with melancholia. This she attributes to change of residence. At that time her husband removed from the house that they had occupied for many years, to another one only a short distance away. She states that the first time she went up stairs in the company of two others, a strange feeling came over her, and if she believed in ghosts she would have thought that the house was haunted. Ever since she has lived in this house there has been this feeling of dislike. It is increasing. No one else experiences this feeling, and she states that her family are as kind to her as is possible. She is unable to sleep in this house, either day or |