2. That other micro-organisms, such as the staphylococcus pyogenes albus, streptococcus pyogenes and bacilli, may, together with the staphylococcus aureus play an infective role. The infection is then a mixed one. The cases depending on such a mixed infection are especially severe in their course, and our prognosis may be determined by the presence or absence of multiple forms of micro-organic elements.

3. It is possible that extended observation will demonstrate that every pus-generating micro-organism may develop typical osteomyelitis in man.

From this it would appear that osteomyelitis is no longer to be strictly considered a specific infection. Those that uphold the specificity of the spontaneous osteomyelitis point out the contrasts that exist between it and the traumatic purulent osteomyelitis. The differences in the features of the two forms may, however, be ascribed to the widely differing modes of infection. In the spontaneous affection the virus is introduced indirectly by means of the circulation, and thus the several disseminated foci arise. In the traumatic form the poison is directly introduced into the medullary cavity and spreads in the tissue. Thus it comes to pass that the manifestations differ, though the virus be the same.

As for the channels of introduction, Kraske considers the integument in first order and reports a case of fatal osteomyelitis that arose from a furuncle of tue lip. Anatomical and bacteriological investigation proved the connection and dependence. The gastrointestinal apparatus does not appear to Kraske a common way of infection, none of his observations pointing so. However, infection through the medium of the respiratory apparatus was clearly made out in one case. A fatal, typical, multiple osteomyelitis developed after a lung affection. Parts of the lung were in a state of hepatization. The examination of these portions and of the bronchial glands showed no cocci of pneumonia; but an abundance of organisms, among

After the poison is once introduced into the circulation, and no local manifestation at the site of entry need develop, certain conditions appear requisite to its local virulent manifestation in bone. We know nothing definite regarding a so-called "disposition." It is not clear, for instance, why, almost exclusively, the period of growth and development offers the most favorable conditions for the infection. In connection with the element of "disposition," so-called, it is interesting to note the cases of recurring osteomyelitis, that is to say, the development in the same individual of successive infections. In such cases the first illness appears to have left such alterations that are favorable to the propagation of germs that find entrance even after years. In this connection Kraske also refers to the "disposition" that other infectious diseases seem to establish. Thus, typical osteomyelitis is known to follow the changes that may persist after typhus and typhoid fever, after scarlatina, measles, small pox, and even vaccination.

MODIFIED CESAREAN SECTION.

From the Archiv fuer Gynecologie, we learn of some modifications of the classical sectio Cesarea that have been proposed and carried out by Professor Kehrer, of Heidelberg. The methods proposed by him have a bearing, also, on craniotomy, and are not so radical as those to which Lawson Tait appears to be inclined, judging from his remarks, lately presented to our readers, in reference to Porro's operation.

Kehrer proposed, some years ago, in cases demanding the Cesarean section, to incise the uterus transversely in the region of the os internum anteriorly. After developing the child and secundines, he suggested union of the uterine muscle incision by deep sutures first. Thereupon, the peritoneum is to be stitched so that the edges are turned in, and

serosa.

Up to date Kehrer operated four times by this method, developing a living child in every case. In two cases the mothers recovered, in the other two the result was fatal. Kehrer states that he would execute a Porro only in case of certain complications, such as sepsis of the utero-vaginal cavity, metritis, multiple fibromata in the region of the fundus uteri, etc.

In all uncomplicated cases he prefers the conservative operation, modified as described. The results of the conservative operation, he claims, are no worse than those of other operations demanding laparotomy.

Kehrer proceeds in a strictly antiseptic way. The belly is scrubbed with sublimate, the vagina is wiped out with an antiseptic solution and an iodoform tampon introduced. The belly is opened by a median incision from umbilicus to symphysis. The incision is then made transversely at the inner os. Thereby a wound that does not gape very much is made, and a matter of the utmost importance, the placentar insertion is not divided by the knife. Another advantage is the close approximation of the edges of the wound, owing to the normal anteverted position of the pregnant and the puerperal womb. The muscle-sutures may be placed before removing the placenta, so that in the event of hemorrhage the cavity can be closed forthwith. The cavity may be treated with an antiseptic. Before closing the abdominal incision the wound and the parametria are sponged with a sublimate solution. Kehrer proposes this in order to hasten the local adhesive process, that is to shut off the uterine and peritoneal cavities from each other. No drainage is made. The first dressing is left undisturbed, unless otherwise demanded.

OPERATION OF HIGH RECTAL CANCER.

Rinne, of Greifswald, reports a case of carcinoma recti, the lower margin of which was situated 11 cm. above the anus, that he

executed and described by Kraske, which we published in the REVIEW, Vol. XII. No. 13.

In order to get at these high neoplasms, Kraske carried an incission from the second sacral vertebra in the median line down to the end of the coccyx; this is then removed; the ligamenta tuberoso- and spinoso-sacrum of the left side are then severed and the left margin of the sacerum is chiseled off in a curved line. Rinne states that all this can be easily done, and the field of operation is made open and accessible. After separating the intestine and opening the peritoneum the carcinomatous portion, 17 cm. in length could be easily drawn forth. After placing elastic ligatures, the gut was divided above and below the diseased section, which was then removed. The intestine was then united by

suture.

COCAINE AND ITS ANTIDOte.

Amyl nitrite is recommended by Schilling, of Nuerenberg, as the antidote of cocaine, Cocaine contracts the cerebral vessels, amyl of a patient that showed alarming symptoms nitrite dilates them. An instance is reported of intoxication after one grain of cocaine had been injected into the gums. Anesthesia, analgesia, amaurosis and deafness ensued. The inhalation of nitrite of amyl at once corrected the trouble, and no nausea or malaise supervened.

QUININE ERUPTIONS.-P. Lavassar, Thése de Paris, sums up as follows: (Journal Cutaneous and Venereal Diseases).

1. Quinine employed internally can, at times, produce eruptions.

2. These eruptions take on a multiplicity of forms, of which one, the scarlatiniform, is of peculiar interest. These eruptions appear suddenly, become general with great rapidity, and are most frequently fugacious.

3. They may, in certain cases, be preceded by general phenomena of marked intensity.

SALOL, A NEW ANTIRHEUMATIC AND ANTISEPTIC.-The Medical News contains the following, reported in the Wiener Medicinische Presse:

Von Nencki and Sahli have discovered and made use of a new combination of salicylic acid, which presents certain advantages over the salts at present in use. In the new compound the acid is chemically combined with phenol, and forms a white, tasteless powder nearly insoluble in water, but quite soluble in alcohol. Experiments show that this compound, called salol by Nencki, is unaffected by gastric digestion, but is, in pancreatic digestion, decomposed into its component parts, which are absorbed and excreted unchanged. Under its use the urine becomes very dark, but no disagreeable constitutional effects are produced. Sahli has himself taken the drug in doses of from ninety to 120 grains without producing ringing in the ears, and in other individuals experimented upon this symptom was always less marked than in the case of an equivalent amount of the ordinary salicylic

salts.

The efficient dose is found to be thirty grains, given three or four times daily. Thus administered, its effects in acute, subacute and chronic polyarthritis and muscular rheumatism, were found to be fully as advanta

geous as those of the exhibition of sodium salicylate, while the fever appeared to be more rapidly diminished.

A case of chronic urticaria, which had resisted treatment for several months, was rapidly cured by this agent, as were also several cases of supraorbital neuralgia.

The fact that the urine of patients thus treated remains unchanged, even when kept at body temperature for weeks, suggests the possibility of the usefulness of this treatment

in vesical' catarrh.

Nencki has obtained good results from the local application of the drug in ozena, otorrhea, and gonorrhea.

SUBNITRATE OF BISMUTH AS A DRESSING.

1. Subnitrate of bismuth possesses antiseptic properties at least equal to those of iodoform. 2. No poisonous effects are to be apprehended as in the employment of iodoform. 3. The subnitrate of bismuth, being a chemically indifferent substance, does not irritate the wounds; secretion is diminished. 4. Its action is very prolonged, though not vigorous, so that the dressings do not require to be frequently changed, and rest is insured for the wounds. 5. There is no action at a distance, nor does any specific effect attach to it. 6. It does not afford protection against erysipelas and other wound diseases, at least no more than iodoform. 7. It is no disinfectant, but as an antiseptic it keeps the wounds pure. 8. All wounds capable of healing by first intention can do so when dressed with bismuth. 9. It also represents an excellent material for forming scabs under which epidermis can grow over the wound. Its use on granulating wounds has not, however, been sufficiently studied as yet.-Annals of Surgery.

-The mild and balmy June has come and gone, and July, with torrid sun is here, with nights so close and warm and full of care, that the encir

cling arms of Morpheus cannot be our share.

We fain would ope our windows wide, but if we do it, we hear a "duet" from the other side, between the musical Thomas and his ephemeral bride, and there are wafted other sounds the housetops o'er, suggesting the old, old query, who, oh who is the author of "The Beautiful Sno-re?"

Alonzo Clarke, Meredith Clymer, John C. Dalton, John T. Metcalfe, New York.

Alfred Stillé, Joseph Leidy, Philadelphia.
Henry I. Bowditch, Boston.

President, Francis Delafield, M. D., New York; Secretary, James Tyson, M. D., Philadelphia; Treasurer, A. Brayton Ball, New York.

The president, in his address, considered. the subject of

CHRONIC CATARRHAL GASTRITIS.

The fact that the lining membrane of the stomach is both a mucous membrane and an organ of digestion does, in a measure, confuse our appreciation of the inflammations of this membrane. We are apt to notice especially the disturbances of digestion and to include all the cases in the general class of gastric dyspepsia.

But the lining membrane of the stomach is, in part, a mucous membrane. It is frequently the seat of chronic catarrhal inflammation, and it then behaves as do the other mucous membranes under the same circumstances.

The ideas which one has as to the causes of chronic catarrhal gastritis, will vary somewhat according to the experience of the hospital autopsy room, and the character of cases observed in private practice. In the autopsy room we find more of the cases associated with complicating diseases, or exhibiting the very advanced lesions of gastritis. Organic diseases of the heart, emphysema of the lungs, cirrhosis of the liver, Bright's disease, phthisis and alcoholism are evidently, in most of the cases, the cause of the gastritis. In private practice, on the other hand, I find most of the cases in adults between the ages of twenty-five and fifty; a smaller number in children and in old persons. In the majority of the cases, no cause is to be discovered other than the mode of life and the character of the locality in which the patient lives. The same climatic conditions which predispose to chronic naso-pharyngeal catarrh and chronic bronchitis have the like effect as regards chronic gastritis. In a smaller number of cases other causes can be discovered. An at

tack of acute gastritis, or of gastro-duodenitis, or of gastro-enteritis may be followed by chronic gastritis. Typhoid fever and the malarial fevers may be accompanied with an acute gastritis, which may assume the chronic form. In some women the disease seems to begin during pregnancy. Alcoholism and the abuse of drugs furnish their quota of patients. Rheumatism and gout are sometimes unquestionable causes. Cirrhosis, Bright's disease, emphysema, phthisis and cardiac disease also furnish a certain number of cases. First among the symptoms comes pain, varying from a mere feeling of oppression or discomfort to the most severe and agonizing pain. Most common is the feeling of uneasiness or discomfort, either following the ingestion of food, or occurring when the stomach is empty. It is not always easy to distinguish this from pain belonging to the small intestine or to the colon. Much worse is the severe pain, due, in some cases, to the presence of food in the stomach, a pain which is often followed by vomiting. At first it only comes on when the stomach contains a considerable quantity of food, but later continuing even after repeated vomiting, so long as the smallest fragment is left, a pain so severe that the unfortunate sufferer has no rest by day or by night, deprives himself of almost all nonrishment, and finally falls a victim to the opium habit.

Nausea and vomiting are also regular symptoms. Vomiting of pure blood is seen in some cases. Vomiting of blood, usually not in large quantities, may occur. Regurgitation of acid fluid, in the morning especially, belongs to alcoholic gastritis.

Retention and fermentation of the food in the stomach are most common with the dilated stomachs, but are by no means confined to them. They are found often enough in other cases of chronic gastritis.

Constipation seems in some cases to depend directly upon the gastritis, and will disappear as this improves without the use of any laxatives. In the same way there are diarrheas which can be cured by treatment directed to the stomach.

Headache is a symptom. It may follow a variety of types, but perhaps the most common is that which comes on at intervals.

A general loss of health, of which emaciation and loss of muscular strength are the most prominent features, is found with the worst cases of the disease. Inflammation of the tongue and a variety of abnormal sensations referred to the throat, mouth and tongue, belong to some of the cases.

These are the most marked symptoms

which may be referred to the gastritis directly. In the complicated cases, of which there are many, other symptoms are added which it is not necessary to consider at the present time.

The course of the disease is naturally prolonged over many years, and interrupted by periods of improvement.

It is evident from the nature of the disease that any treatment intended not merely to palliate but to cure, must be of long duration, and that it must be repeated from time to time when the inevitable relapses occur. The different plans of treatment which may be adopted are: (1) The curative treatment of climate and mode of life; (2) the regulation of the diet; (3) the administration of drugs, and (4) the use of local applications directly to the inflamed membrane.

Climate and Mode of Life. These I believe to offer the most certain means of curing chronic gastritis. It is unnecessary to lay down rules as to the sort of climate. That can be regulated by the tastes of the patient. The two points of importance are, first, the locality selected must be one where the patient can live an out-door life; and second, the patient must live in this climate either for several years, or for a considerable part of each year. Excellent as this method of treatment is, it is evident that it can be carried out only by a limited number of persons.

The Diet. The regulation of the diet is a matter which demands consideration in every case of chronic gastritis. In trying to ascertain the best way of feeding these patients, I have found only one satisfactory method, and that is to feed them experimentally with different articles of food, and then, after an interval of several hours, wash out the stomach and see how thoroughly these articles of food have been digested and removed from the stomach. After pursuing this course for a number of years, I have arrived at the following conclusions:

It is necessary that the patient should be well fed, a starvation diet never answers.

The stomach does not require any rest from the stomachic digestion, on the contrary, it is all the better for being called upon to perform its natural function.

The patients own ideas as to what food agrees with him are usually erroneous. They are apt either to starve themselves or to select the least nutritious articles of food.

The use of artificially digested foods, or of substances such as pepsin to assist stomachic digestion, is unnecessary.

The starches, oat meal, corn meal, bread, the cereals, the health foods, are, as a rule,