Clinic of the Month.

Transfusion of Blood in Anæmia.-Dr. Barnes observes that there is nothing more sad than to see a woman in labour or childbed bleed to death. It is surely, he remarks, a just reproach to the medical art if such a catastrophe occur. The first thing to study is how to obviate the causes of hæmorrhage; the second is how to put a stop to hæmorrhage when actually present and threatening to continue; the third is how to rally the system from dangerous exhaustion induced by the loss of blood.

The highest achievement of medical science would undoubtedly be to secure the first of these three ends, and thus to exclude all necessity for considering the remaining two. Unfortunately we cannot in all cases command all the essential conditions. We must therefore make up our minds how to deal with hæmorrhage and its effects. The number of cases in which hæmorrhage cannot be averted, now that we have so effective a resource in rebellious cases as the topical use of perchloride of iron, is becoming more limited every day. Still, even in some cases where hæmorrhage has been stopped, life may ebb away unless restorative means be applied. The greatest of these is transfusion, and Dr. Barnes rejoices to see the revival of this operation concurrently with the extending use of the perchloride of iron. The following case, although not successful, is not without interest in several points :-A short time ago Dr. Barnes met Dr. Devereux, of Tewkesbury, at a case of extreme exhaustion from secondary post-partum hæmorrhage. At one time it was thought the patient was dead, so utter was the prostration. The pulse rallied now and then, but often flagged so that it became imperceptible; the respiration was laborious and frequent, so loud that it could be heard in the adjoining room; the face and extremities were cold; the voice almost extinct. She swallowed beef-tea and port from time to time, but soon vomited all. This was about 3.30 P.M. The extreme prostration, and the hopelessness of getting any nutriment absorbed either by stomach of bowel, led us to look upon transfusion as the last hope. Discussing the means of accomplishing this, we found the best we

could do was to use an aspirator-syringe. This had to be fetched at a distance of five miles. In the meantime, the gardener offering his arm, at 10 P.M. the operation was carried out. The syringe being made on the principle of the stomach-pump, with reversible action, answered extremely well. The point of the aspirator-trocar was filed down, and this served very fairly for insertion into the patient's vein. As circumstances left no choice between immediate and mediate transfusion, it became necessary to defibrinate the blood. The man who yielded the blood was fat, and his veins small, so that it was with difficulty four ounces were obtained. This was defibrinated by whipping with a silver fork and filtering through a cambric handkerchief. Believing that one factor in the danger attending these cases of prostration is the merely dynamic one arising from the absence from the heart and vessels of fiuid to act upon, and considering that he had so small a quantity of blood at his disposal, Dr. Barnes first filled the syringe with a solution of phosphate of soda, carbonate of soda, and chloride of sodium, at a temperature of 100° Fahr. Pumping this through the syringe also served to get rid of air from the apparatus. The vein in the patient's right arm was found by pinching up a fold of skin, transfixing it transversely to the course of the vein, and then dissecting through a little fatty cellular tissue. It was then pinched up by forceps, and a sufficient opening made into it. The trocar was passed one inch and a half into it. The injection was then slowly made. The blood was partly mixed with the saline solution; altogether about six ounces of fluid, including all the blood, was thrown in. Almost instantly the pulse improved, warmth spread over the body, the face and manner became more natural, the respiration became tranquil, and hope was entertained that she might pull through. Everything was prepared for repetition of the transfusion in the morning should the condition be favourable. But the rally was short; the respiration again became moaning, rapid, and laboured; the pulse flagged, and the patient sank at 1.30 A.M., about three hours after the injection. (Lancet, Jan. 3, 1874.)

Treatment of Diphtheria with Calomel and Soda.-Dr. Duer, of Philadelphia, extols the efficacy of small doses of calomel and large doses of the bicarbonate of soda, and the free use of nutritious food and brandy, in diphtheria. He states that he has treated a large number of cases of all grades of severity by this plan with satisfactory results, which he says was first suggested to him by Dr. Harlow. Two cases are related to illustrate this mode of treatment. Grace V., aged five, previously strong and well, after short prodromic symptoms and a marked chill, presented all the general and local evidences of diphtheria. Her

sister Alberta, aged seven, was taken sick the same morning, and presented an almost identical condition. The former had ten grains of chlorate of potash every third hour, as recommended by Vögel, and the other one-eighth of a grain of calomel and five grains of bicarbonate of soda. A weak solution of carbolic acid as a disinfectant was applied locally, and the same supporting and stimulating plan was adopted in both cases. The following morning there was little change in either case. On the evening of the second day, however, there was the most marked improvement in Alberta, while Grace's symptoms showed little evidence of yielding. Dr. Duer now withdrew the calomel and continued the soda. By this time, in this case, the false membrane was coming away in detached fragments; but in the other child there had as yet been no change for the better. On the evening of the fourth day, Alberta's tonsils were again covered with false membrane; calomel was again given for twenty-four hours, with the same positive result. From this time the soda was depended on entirely. At no time was there the slightest ptyalism, but as soon as the child had been long enough under the influence of the calomel, the false membrane seemed to yield up its connection with the tonsils, while at the same time the general symptoms began rapidly to abate. On the morning of the fifth day the temperature had fallen to 99° and the pulse to 90, and from that time she steadily improved under the use of tonics and nutritious diet. On the other hand, Grace, to whom the chlorate of potash had been given, continued so ill that Dr. Duer substituted the calomel and soda treatment on the fourth day, with a like immediate result, so far as the local trouble was concerned; but her convalescence was tedious, and was subsequently complicated with bilateral paralysis of the palate and lower limbs. In the course of a few weeks Dr. Duer treated five other children in the family by the same plan, with complete success. (British Medical Journal, Jan. 3, 1874.)

Treatment of Syphilitic Affections of the Nervous System. Dr. Broadbent, in his Lettsonian Lectures on this subject, remarks that the one remedy is iodide of potassium; or, this failing, mercury. He usually begins with doses of six grains, and always combine with it ammonia-the carbonate or aromatic spirit. Having by one or two days' experience ascertained that there is no special intolerance of the iodide, it may rapidly be pushed to doses of twelve, eighteen, twenty-four, thirty, or thirty-six grains, three times a day; occasionally, even larger doses are necessary, and he has given a drachm every four hours. That large doses are often absolutely required, and that they succeed when moderate doses fail, he is convinced by abundant experience: and if iodism is induced, which is very

rarely the case in tertiary syphilis, it is almost always before large doses are reached. Large doses are better borne when taken after meals. Of course iodide of potassium is more quickly taken up into the blood from an empty stomach; but it is also quickly taken out of the blood and in the urine; and when a continuous action on the system is needed, which is what we require in dealing with the effects of tertiary syphilis, the indication is best met by giving so diffusible a remedy as the iodide of potassium after food. If the iodide of potassium fails after a full and free trial, a resort to mercury is always desirable, and the more acute the syphilis the earlier. When passing from the use of one drug to the other, either a certain interval should be allowed to elapse, or the mercury, if given by the mouth, should be in one of its most soluble and active forms, the bichloride or biniodide. Occasionally, sudden and profuse salivation will occur when this precaution has been neglected, no doubt from the mercury being converted into biniodide within the system. Sometimes mercurial inunction may be employed at the same time with internal administration of iodide of potassium; and Dr. Broadbent says that frequently he has given biniodide of mercury with iodide of potassium, either in the same mixture or in the form of pill at night. One word as to the modus operandi of iodide of potassium. This was the subject of a beautiful explanation by Dr. Odling, in his Gulstonian Lectures before the College of Physicians, hypothetical at that time, but demonstrated by experiment since. The active agent is the iodine, as shown by the fact that other salts of potassium have not the same effect, while other combinations of iodine, such as iodide of ammonium or sodium, have. The iodine is permitted to exercise its influence on the seat of disease in virtue of the comparatively slight affinity by which it is held in union with the base, this being so feeble that in the presence of certain forms of living protoplasms in active change, the salt is decomposed, and the iodine set free to exercise its solvent action on the organic matters. Whether this is direct or indirect, through the well-known oxidising effects of free iodine, is not so certain. (Lancet, Feb. 21, 1874.)

Treatment of Cerebro-spinal Meningitis.-Dr. Dowse, of the Central London Sick Asylum, after giving a good account of the etiology, symptoms, and post-mortem appearances of this disease as it affects the base of the brain, observes that there is no disease requiring more constant watching or careful medical interference than this. He has seen an acute meningitis and myelitis treated with those drugs which produce congestion; for instance, opium and strychnine. Nothing can be productive

of more harm than this administration in the first or acute stage.

1. It has to be considered how to relieve the vessels of the cord and to equalise the action of the vaso-motor system of nerves. Nothing appears to be of greater service in effecting this than the ergot of rye and belladonna. The former he has prescribed in decided doses, such as half a drachm of the powder every four hours; and the latter he has applied to the spine in the form of a belladonna paste, made by mixing the extract with one-third its weight of glycerine.

2. To check the reflex vomiting, small pieces of ice must be swallowed, not sucked, as the full effect of its sedative influence upon the stomach is then attained.

3. To relieve constipation, Dr. Dowse prefers the administration of a pill of the watery extract of aloes, for the reason that it acts upon the mucous membrane of the rectum and dilates the hæmorrhoidal veins.

4. To relieve sleeplessness, both chloral and bromide of potas sium have proved ineffectual; but what he found of most service was a suppository of eight grains of the extract of henbane, with four of the extract of conitum.

5. One essentially practical point must not be forgottennamely, to keep the paralysed bladder constantly free from urine. It is not sufficient to draw off the water night and morning, which is the course usually adopted, but a self-retaining catheter must be kept continually in the viscera.

6. In reference to diet, it ought to be both nutritive and stimulant from the first.

7. There is a stage in the treatment of this disease when quinine in large doses becomes of the most signal value-at that crisis when exhaustion appears imminent; the skin covered with sweat; sudamina and bullæ over the body; temperature 102° to 105°; pulse small, weak, and over 120. But more especially is quinine invaluable when rigors supervene; it never fails to have a good effect. But it must be given in ten or even twenty grain doses and if the stomach cannot tolerate it, it must be introduced into the system by the rectum.

8. The detraction of blood, either local or general, is not advisable. (Medical Times and Gazette, Feb. 7, 1874.)

Treatment of Diabetes.-Dr. Brunton, after giving a full account of the pathology of diabetes as far as our present knowledge of it extends, makes the following observations on the treatment of diabetes. The patient must be supplied with a diet consisting of nitrogenous food, such as butcher's-meat, fish, eggs, and soups. Fat (which does not contribute in the least to the formation of sugar) may be given in all its forms, such as