stops when person's attention is fully occupied; is most marked when patient is under observation; if stopped for a time, begins with an explosion; is usually absent at night, always if purely nervous; absence of physical signs in respiratory tract; cough apparently a useless one, as it does not accomplish anything; patient complains of usual symptoms of catarrhal cough in the respiratory tract; its tone is various, sometimes hacking, bellowing, shrill, croupy, metallic, at other times hoarse from insufficient cord tension. This latter is an imperfect cough, and somewhat distinctive of thoracic tumors or aneurism pressing upon the recurrent laryngeal nerve. Its chief features are hoarseness and imperfect explosion; it is a noisy, not infrequently harsh, brassy cough. Especial care is to be taken that the early stage of severe affections-as neoplasms, aneurisms, and the like-be not confounded with purely nervous cough; though a reflex cough, it may be the earliest symptom of serious trouble.

The central origin of nervous cough is highly probable. In this group are the coughs of laryngismus stridulus of children and adults, hysteria, chorea, tabes, epilepsy, and neurasthenia. Various irritations excite the reflex. Combined with the irritation, whether of rickets, an overloaded stomach, or what not, there is always a hyper-excitability of the central nervous system. In adults glottic spasm is most commonly due to hysteria.

Reflex cough of uterine origin is common, and, as is well known, is often one of the early manifestations of pregnancy. Coughs having their point of irritation in the stomach, bladder, intestines, and liver, are not infrequent. Ear cough is one of the rather common reflexes. It originates from pressure or irritation in the external canal.

Acute Mastoid Abscess-Perforation in the Posterior Portion of the Mastoid (Bezold's).

Recently at the Westminster Hospital (Med. Press. & Cir., vol. 67, no. 3139) Mr. de Santi operated on a man, æt. about 47, who had been admitted under him with acute mastoid abscess. The history was that the patient had had an attack of facial erysipelas, after which he had profuse fetid discharge from the ear. This was followed by the formation of a large, deep-seated cervical abscess, extending from the mastoid process to the level of the thyroid cartilage. There was a large, sloughing mass in the external auditory meatus. The patient had a high temperature and looked very ill. After the administration of an anesthetic an incision was made over the mastoid, extending right down to the abscess, which was found to be underneath the deep cervical fascia, and from which a large quantity of pus was let out. The mastoid antrum was opened in the usual way and the pus evacuated from it. On careful examination perfora. tion of the mastoid bone was found in its deep or posterior aspect, and this perforation communicated with the abscess cavity in the neck (Bezold's perforation). The whole of the parts were then thoroughly dried and drained. Mr. de Santi said that Bezold's perforation was an uncommon condition to find, but he considered that it was most important for the surgeon to bear in mind that such a complication might occur, for unless the mastoid bone itself were operated on in such cases, the deep-seated cervical abscess which resulted from the perforation would not heal.

The patient did very well till three weeks later, when he got a sudden attack

of cutaneous erysipelas on the other side of the face. This caused serious constitutional symptoms and profuse suppuration from the old abscess cavity. The case was treated with antistreptococcic serum by the house physician, and the patient made an excellent recovery.

Peritonsillar Abscess.

Sedziak (Vienna Cor. Med. Press & Cir., vol. 68, no. 3142) records the history of six cases of peritonsillar abscess treated with gargle and hot fomentations. Several extended aditus ad laryngis; in one case paralysis of the recurrent nerve followed excision of tuberculous glands in consequent infiltration. This case is interesting from a physiological point of view, showing the effect on the soft palate of one side of the mouth after cutting the tragus.

Sedziak, in his diagnosis of this disease, records the history of 8500 cases of inflammatory condition of the fauces, root of the tongue and pharynx, resulting in purulent accumulation, and concludes that 235 are peritonsillar in character, or 2.76 per cent. They are also affected by season, mostly occurring in the spring and autumn. The greatest incidence is on males at the age of 20 to 30 years. It is difficult to say how far the abuse of nicotine and alcohol affects the origin. The immediate cause is the pyogenic bacteria, which may be retained on the roof of the mouth till a retention of the tonsillar secretion occurs to admit germination. He has frequently seen follicular tonsillitis after influenza and muscular rheumatism, but more frequently with hypertrophy of the tonsils. Those of a lymphatic constitution are more prone to the disease. Death may occur from erosion of carotis interna, edema of larynx, or bursting of large abscess during sleep, and suffocation.

Treatment of Dysphagia in Tubercular Laryngitis with a Product of Microbe Culture.

Lavrand (Revue Hebdomadaire de Laryngologie, etc., vol. 20, no. 30) has made some clinical observations upon the use of a product extracted from cultures of the bacillus of Koch in the treatment of the dysphagia of laryngeal tuberculosis. This is given in dosage of from ten to fifteen drops during the day, and the results of his experiments have led him to offer these conclusions concerning this remedy:

1. It is absolutely harmless. It strengthens the patient.

2. It calms the dysphagia in laryngeal tuberculosis, and also spontaneous pains when they exist.

3. It exercises a favorable action on very advanced laryngeal lesions.

4. It gives results in the cases where all ordinary means of relief fail.

[NOTE. We should infer that this product is nothing other than Koch's new tuberculin. "T R."]—EDITOR.

The moon is at her full, and, riding high,

Floods the calm fields with light.

The airs that hover in the summer sky

Are all asleep tonight.-Bryant.

[Prevailing atmospheric conditions as we go to press justify this quotation.]—ED.

GYNECOLOGY.

UNDER CHARGE OF T. J. CROFFORD, M.D.

Consulting Gynecologist to St. Joseph's Hospital, Memphis, Tenn.

Retro-Uterine Hematocele.

At a recent meeting of the Societe de Chirurgie, M. Routier (Med. Press & Cir., vol. 68, no. 3142) spoke on the treatment of retro-uterine hematocele, and said he was a partisan of opening the tumor through the posterior cul-de-sac. M. Chaput admitted that that mode of treatment was excellent, but sometimes the patients lost a good deal of blood. One of his patients operated at the Tenon Hospital succumbed in this way. After having incised the posterior cul de-sac and evacuated the tumor, he plugged the wound with iodoform gauze. In the afternoon the patient developed all the signs of internal hemorrhage, and died before help arrived. Ever since he was careful to place only a simple plug and to wait events; if the hemorrhage continued he performed laparotomy.

M. Lucas said he would never incise an hematocele per vaginam. Laparotomy was the operation indicated in such cases, as it permitted the inspection of all the points which might bleed. M. Pozzi never witnessed the slightest accident following the opening of the posterior cul-de-sac. He had seen more than once serious hemorrhage occur, but he could always control it by hot injections and plugging. However, in extrauterine pregnancy laparotomy was indicated.

M. Regnier considered it was always very difficult to distinguish between extrauterine pregnancy and hematocele. It was always where the hematocele was recent that the danger of profuse hemorrhage existed. Consequently, it would be well to postpone interference, one way or the other, for three weeks after the first symptoms.

Observations on the Early Use of Purgatives after Abdominal Section.

Ramsay (Amer. Jour. Obstet., etc., vol. 40, no. 259) arrives at these conclu

sions:

1. That it is important, both for the welfare of the patient and for the comfort of the operator, to attend carefully to the diet and to the thorough emptying of the bowel before any abdominal operation.

2. That the bowels should be moved and the distention relieved soon after operation, both for the comfort of the patient as well as to avoid possible dangerous complications.

3. That in the simpler groups of operations, such as suspensions of the uterus, myomectomies, the removal of uncomplicated ovarian tumors, and in uncomplicated hysterectomies, the administration of the calomel and use of enemata on the second day is followed by a perfectly satisfactory convalescence.. 4. That in cases of beginning peritonitis, in cases where adhesions have been broken up or large raw areas left, in cases where the intestines have been freely handled or long exposed, and, finally, in emergency operations where no previous preparation can be made, Dr. Byford's method of immediate purgation is indicated.

Radical Changes in the After-Treatment of Celiotomy Cases.

Ries (Jour. Amer. Med. Assn., vol. 33, no. 8) finds that after intra-abdominal work done by the vaginal route with subsequent complete closure of the peritoneum and vagina by sutures, patients can be fed like perfectly healthy persons. He allows them to get up within twenty-four to forty-eight hours and to leave the hospital four to six days after their vaginal celiotomy. He has never insisted on causing the bowels to move within the first few hours after intra-abdominal operations, and has found it easy to make them move with a simple enema on the first or second day after the operation. Often if left alone they move naturally. The author argues, in support of his practice of early and full feeding, that a well-filled intestine and regular peristaltic motion are the only reliable means of breaking up old and preventing the formation of new adhesions. Author has never had a case of ileus after vaginal operation, and in over a hundred vaginal celiotomies in four years, has not had a single death. His cases leave the hospital within a week from the operation in cases of vaginal celiotomy, and within ten days from the date of the operation in the cases of vaginal hysterectomies, if done with the suture method, and since they do not lie in bed until their muscles become atrophied from inactivity, they are strong and able to go to work at once. The author has seen neither vaginal hernias nor hemorrhages, external or internal, nor any other kind of subsequent trouble that could be attributed to this after-treatment. His patients do not wear a binder of any kind or shape after their ventral incisions, and the author has yet to see the first hernia. Also he states that he does not use any drainage.

Conservative Pelvic Surgery.

Eastman (Med. & Surg. Monitor, vol. 2, no. 8), under this heading, lays down the following rules for guidance in the practice of conservative pelvic surgery:

1. An ovary should not be removed simply because the tube of its side has been taken out.

2. Wherever it is possible in cases of parovarian cyst, the ovary should be left.

3. In cases of adherent ovary, every effort should be made to so relieve its adhesion as to not tear it out from its insertion into the broad ligament, with a view of leaving it intact.

4. So-called Graafian cysts may be punctured with a knife or scissors, or by cautery.

5. Hematomata may often be dissected out where they do not involve too much of the ovarian tissue.

6. Frequently dermoid cysts of the ovary, ovarian cystomata and ovarian abscesses may be so manipulated as to preserve the functions of the ovary.

7. Tubes may be preserved not infrequently by proper care. Adherent tubes are released, strictured tubes are opened, and tubal abscesses may be frequently drained.

VOL. XIX-27

OBSTETRICS AND PEDIATRICS.

UNDER CHARGE OF E. P. SALE, M.D., MEMPHIS.
Obstetrician to the City Hospital.

Gruels in the Feeding of Infants.

Chapin (Med. Rec., vol. 56, no. 6) says that he has tried all kinds of infant feeding with that hardest class of cases, bottle-fed babies, in hospital and dispensary practice, and that by adding gruel to the milk the best results are obtained with these babies. The theory is that the cereal will help attenuate the curd of cow's milk and aid in the nourishment of the baby. The gruel should be dextrinized by the use of diastase. This can either be produced cheaply at home or purchased at the nearest drugstore. A simple decoction of diastase may be made as follows: A tablespoonful of malted barley grains, crushed, is put in a cup and enough cold water added to cover it, usually two tablespoonfuls, as the malt quickly absorbs some of the water. This is prepared in the evening and placed in the refrigerator over night. In the morning the water, looking like thin tea, is removed by a spoon or strained off, and is ready for use. About a tablespoonful of this solution can be thus procured, and is very active in diastase. It is sufficient to dextrinize a pint of gruel in ten or fifteen minutes. The gruel is made as follows: A tablespoonful of wheat flour or barley flour is beaten up into a thin paste with a little cold water, and then stirred in a pint of water, which is boiled for fifteen minutes. When cool enough to be tasted, a tablespoonful of the above solution, or a teaspoonful of malt extract or preparation of diastase, is added, and the mixture stirred as further cooling takes place. The great bulk, if not all, of the starch will be thus dextrinized in about fifteen minutes. The previous boiling is for the purpose of gelatinizing the starch, so that the diastase can act to advantage. The gruel is now ready to be used as a diluent of cow's milk, and can be assimilated by the youngest and weakest infant.

In average cases, and if the bowels tend to looseness, wheat or barley flour may be used. When there is constipation, oatmeal had better be employed, on account of the fat it contains. According to Dietrich and König, the percentage of fat in these cereals is as follows: Barley, 2.09; wheat, 1.55; oats, 6.09. It is difficult to procure barley flour, except as it is to be purchased in the form of prepared barley by certain manufacturers. Some coffee-grinders are fine enough to make a coarse flour out of pearl barley, and a satisfactory gruel can thus be made. The barley grains themselves, however, may be used if flour is not available. A tablespoonful of barley is soaked over night in a little cold water; this water is then removed and the barley boiled for five or six hours in a pint of water, replenishing the water as it evaporates below the pint; it is then strained and ready for use. As wheat flour is procurable in every house, it is a desirable basis for making gruels. In hot weather dextrinized gruels constitute a refreshing and nourishing drink for babies when milk in every form must be temporarily abandoned.

Recently some foreign observers have claimed excellent results in infant feeding by the use of what they call "malt soups." In the Medical Record for January 14, 1899, a quotation is given from the Deutsche Medicinische Wochenschrift (September 28, 1898) in reference to some investigations made at the