(toilipt JJlcdiral Sitcratttijc. MEDICINE.

The Gouty Heart.?(ThePractitioner, January, 1895.) Dr. Mitchell Bruce says there is re;tson to

suspect the gouty nature of a cardiac attack under the following circumstances, or various combina- tions of them :?

"(1) A personal history of declared gout, pre- sent or previous ; (2) a personal history of free living, and usually of hard work, with occasional explosions suggestive of irregular gout, in the form of ha3morrhage from the bowels, intestinal

fluxes, sick headaches, irritability of the bladder, eczema, insomnia, and fits of irritability or depres- sion ; (3) relief of these symptoms by treatment directed against gout,?purgatives, spare living, and various alkaline salts ; and (4), a family history of gout, megrim, gravel, glycosuria, asthma, and their allies?well marked, direct, and often on both sides."

Regarding the pathology of the gouty heart, Dr. Mitchell Bruce says :?

"(1) We know that gout causes dyspepsia, flatu- lency, and local and perhaps reflex cardiac distress and irregularity. Some of the worst cases of

angina are relieved by eructation. "(2) We know that at the other extreme of the

scale there are unquestionably associated with gout certain degenerative changes in the arterial system, at the root of the aorta, at the aortic opening and in the coronary arteries, in the myocardium and in the substance of the mitral segments too.

"

(3) Gout, or the poison of gout, appears to

act upon the neuromuscular structures in and con-

nected with the heart, as we know it acts upon other organs of high rank in the economy, parti- cularly the brain. Without attempting to be scien- tifically exact, we may safely describe the functional condition of the brain or heart under the influence, of uric acid as a condition of weakness with

irritability. The despondency, dulness, impatience irascibility, restlessness, and sleeplessness on the side of the brain may be justly compared with the faintness, sinking, pain, oppression, flushes, and

palpitation on the side of the circulation. Such effects of uric acid on the heart and vessels and their extensive nervous mechanisms would natural- ly be temporary, periodic, and perhaps paroxysmal, like the more familiar effects of it elsewhere.

"(4) We shall also probably be near the mark if we accept strain as a predisposing cause of gouty manifestations in the heart, as we find in other parts of the body. It is impossible to resist comparing the advent of an attack of palpitation, intermittent pulse, or angina in gouty man who has run to catch a train in the course of the previous day,, with the ' election

' in the same subject of the

great toe, the heel, the loins, or an injured joint wherever situated.

" If we now keep before our minds these four

sets of considerations, we may be able to draw a

picture?far from exact, no doubt, but still instruc- tive?of the pathogeny of gouty heart. We ob-

tain a composite presentment of a heart in a-

temporary, or occasional, or permanent difficulty :

a heart embarrassed in its function of maintaining such a display of force as shall overcome peripheral resistance ; embarrassed mainly in consequence of intrinsic disability, occasionally also, no doubt, in consequence of extrinsic difficulty?an unreason- able rise of resistance ahead." The prognosis in cases of gouty heart is favour-

able according to the writer's experience, he finds

patients who suffer from these cardiac attacks live for years. Structural disease of the heart with contracted kidney are not associated as a rule with- the typical gouty heart.

The prospect of relief in cases of gouty heart depend on a correct diagnosis and proper treatment. The latter must be mainly of a general kind, gentle exercise without strain or effort, a mildly bracing climate ; mineral waters such as those obtainable at Homburg, Leamington, and Buxton. The diet should be spare in amount, though it may be of the ordinary mixed kind. A fair amount of water should be taken at each meal, and Vichy water is

perhaps the best. In many cases a small, fixed amount of whisky or pure red wine may be given at meal times ; but white wines and beer should be avoided. Tobacco should be absolutely inter- dicted. Drugs may be of value if selected with discrimination. Mercurial or saline purgatives are often very beneficial. The writer finds Plummer's

pill, taken every second night for a fortnight, highly successful.

" Next to purgatives, the drugs that give us most satisfaction are iodide of potassium, arsenic, strychnine, and digitalis with its allies. If pain be a prominent feature, iodide should be ordered in combination with alkalies ; if faintuess, strych- nine, variously combined. Arsenic and strychnine make a valuable combination in some instances. The use of digitalis demands judgment.

* * *

"

During the anginal seizures we naturally trust to the nitrites and nitro-glycerine, which are so

powerful and so swift in their action.. In rnor

160 INDLAN MEDICAL GAZETTE. [April 1895.

prolonged instances I would give a hypodermic injection, consisting of two minims of the Phar-

macopoeial injection of morphine and two minims of the Pharmacopoeial solution of hydrochlorate of strychnine?that is, 4-th and -^-tli of a grain, respectively, of the two drugs. The effect of this

? combination on a disabled heart is often extremely satisfactory."

Disinfection.?(La Tribune Medicale). M- Meillere recommends disinfection of sick-rooms, clothes, &c., by fumigations with the derivatives of benzoine. No special apparatus is required, a spirit lamp and a porcelain dish containing the volatile substance will suffice. He gives a list of antiseptic substances belonging to the aromatic series which may be used for this purpose ; but

preference is given to resorcin. Whatever vapour

may be used its efficacy is intensified by evapora- ting hydrochloric acid simultaneously in a separate vessel.

Test for the Contamination of Well-Water. ? The Practitioner quotes from the Journal d'Hygiene a simple method to ascertain if a cess- pool communicates with a well of drinking water. Pour into the cesspool about a pint of fluorescin, 8 ozs. to 1 g pint of water. In a very short time, if any communication exists, the well-water will be coloured a deep red.

Diuretin.?(Australian Medical Journal.) Diu- .retin is a compound of salicylate of theobromin and soda, its action resembles that of the salts of caffein without their disturbing influence on the brain. It is a direct diuretic as well as a cardiac stimulant. Dr. James Jamieson considers it a

safe remedy without any cumulative tendency. When 20 grains given thrice daily do not suffice, he considers that the dose should be pushed to 30 ?Trains or even more.

The Infective Period of Syphilis.?(.Boston Medical and Surgical Journal.) Dr. James Bell

instanced the case of a man who received regular specific treatment for two years after the appear- ance of a characteristic primary sore. At the

end of this period all secondary symptoms had entirely disappeared. Eight months later he

married, and about a couple of months after mar-

riage his wife developed unmistakable signs of syphilis.

Diabetes Insipidus.?(The Practitioner, Janu-

ary, 1895.) Dr. Saundby recommends that the urea excretion should be watched in all cases of

diabetes insipidus, because the disease may end

fatally in ursemia when it is persistently reduced below the normal amount. He quotes Dr. Ralfe's table :?

At 5 years urea 180 grains. ? 12 ? ? 320 ?

,, 21 ,, , 535 ,,

? 40 ? 555 ?

But he considers these figures too high for a patient on a milk diet, and believes

" the case is safe so long as the daily amount exceeds 300

grains." Treatment of Typhoid Fever.?Dr. C. W.

Dulles of Philadelphia, has published in pamphlet form a paper on this subject which he read before the College of Physicians of Philadelphia. He summarises the principles of the treatment of

typhoid fever thus :?" (1) Careful maintenance of the natural processes of excretion ; (2) the

judicious administration of food, finding a mean between starvation and over-loading the alimentary canal; (3) moderate regulation of temperature ;

(4) medication reduced to the lowest possible point and shaped to meet definite indications." He considers it of the utmost importance to

maintain the natural processes of excretion of the

lungs, skin, kidneys and bowels. He maintains that much of the delirium of typhoid fever might be avoided if as much attention was paid to the

kidneys as is usually given to the bowels. The

urine should be frequently examined for albumen and tube-casts, and any tendency to hyper-acidity of the urine should be controlled by the free use of water and dilute alkaline solutions, e. g., acetate of potassium and liquor ammonii acetatis. As regards the bowels he believes that too much fear is frequently entertained for the diarrhoea of typhoid fever. "This diarrhoea is the result of

nature's efforts to get rid of material that is inju- rious to the patient ; and I believe, on the one hand, it would be less likely to occur if the phy- sician secured proper evacuations from the bowels before the diarrhoea began, and, on the other hand, that lives are sometimes sacrificed in a desire to check it." He recommends thorough clearing out of the entire intestinal track at the outset of the case by several moderate purgative doses. After

this, if necessai-y, mild saline laxatives, like Rochelle salts, or small and repeated doses of calomel, should be given about every third day. Astringents are rarely needed, and simple lave- ments, or irrigation of the colon, are preferable. He lays great stress on the judicious adminis-

tration of food. '* I am sure I have seen patients killed by relentless feeding, practised by physi- cians who have, without judgment, followed the teachings of writers who advocate what is called

'regular' feeding, and especially with milk-food, in typhoid fever. Forcing patients to take measured quantities of milk at short intervals sometimes results in a diarrhoea which shows that nature

repudiates the imposition?the stools resembling those of sick, milk-fed infants. At other times, when milk is given, the milk-water and salts are absorbed while the casein remains undigested and accumulates in the lower bowel until a condi- tion of coprostasis is set up, in which the patient is subjected to the dangers of total obstruction to elimination from the bowels and to horrible pains and violence when the mass of solid fa3ces is

April 1895.] CURRENT MEDICAL LITERATURE. 161

finally expelled by an act of nature or by the sti- mulation of cathartics." He does riot favour the use of extracts of beef ;

but prefers beef-tea, cool water with the white of an egg stirred up in it, almost any clear soups, milk, plain or peptonized, or combined with cocoa. He also allows tea and coffee, with plenty of cream and milk, and eggs, either soft-boiled or shirred. If the bowels are acting well, he permits custards and corn-starch preparations.

"

My own rule which I have found has been that of others?in almost all cases of sickness, in young and in old, is to say that patients may eat when they wish to, and go without eating when they have no desire for food. I let them drink all they want to, and give them food which shall resemble as little as

possible those trying things that remind a patient of this sickness."

As regards the regulation of temperature Dr. Dulles eschews the use of drugs, and relies 011 cool air, cool water, and removal of all unneces-

sary bed-clothes. " I have found that sponging

with cool water, especially upon the abdomen, is pleasant to the patient.

* * * In some cases I .advise that a few light layers of muslin or gauze, such as surgeons use, be laid upon the abdomen .and moistened at times with ice-water gently squeezed from cotton or a sponge."

Medication he reduces to the lowest possible limits, and then only to meet definite indications. The use of purgatives and diuretics has already been alluded to. Certain intestinal antiseptics are of value, especially turpentine and salol if used in moderation. To procure sleep sodium bromide, sul phonal, or trional may be used, and in rare

cases morphine. " Alcoholic stimulants are

seldom required, and never in the large quantities sometimes prescribed. There are times when a dose of a teaspoonful of whisky in a little hot

water, repeated every ten minutes, may tide over a short period of weakness or collapse ; but I think the administration of such quantities as 8 01* 16 ounces of whisky in the 24 hours is not good practice; while I believe that hot tea or coffee, without cream or milk, may be used instead of the smaller quantities of alcohol just mentioned."

Hypodermic Injection of Sulphate of Mag-

nesia.?(The Australian Medical Gazette, 15th

January 1895). Dr. G. 11. Eakins recommends the hypodermic injection of a solution of sulphate of magnesia, 2^ grains in 10 minims of sterilized water, at intervals of 2, 3, or 4 hours for the relief of obstinate constipation or frocal impaction. The Prevention of Phthisis.?(The Medical

Press and Circular, December, 1894). Dr. W. Murrell suggests the following practical points for combined or legislative preventive measures against the spread of phthisis :?

"1. The ultimate inclusion?when public opin- ion is ripe for that step?of consumption in the

list of notifiable diseases.

" 2. Public and official announcement of the fact that in the event of a person having died of consumption the rooms occupied by him will be dis- infected by the sanitary authorities free of charge.

" 3. The passing of an Act making it illegal to let any house or room in which any person within two months lias suffered from consumption with- out having had it properly disinfected.

" 4. To make it an offence punishable by fine or imprisonment for any person letting a house or room to wilfully conceal or deny that there had been consumption in the house.

" 5. To call the attention of shipping agents to the fact that there is danger to a healthy per- son in occupying the same cabin with a consump- tive, especially on long voyages, and when from the inclemency of the weather the passengers are not much on deck.

" 6. To make it compulsory for a consumptive person taking a long voyage by sea to notify the nature of his complaint before starting.

" 7. To call the attention of railway companies on lines connected with well-known health resorts for consumptives to the necessity of having the sleeping carriages carefully cleaned with some

disinfecting solution, and above all thoroughly aired.

" 9. The exercise of greater care in the inspec- tion of carcases intended for food and the compul- sory rejection of those exhibiting indications of the tubercular disease.

" 10. The rejection as an article of food of the milk of tubercular cows.

"12. The prevention of overcrowding amongst animals intended for consumption as food.

" 13. The prevention of overcrowding amongst people bv regulating the amount of cubic space allotted t.) each person in common lodging houses, workshops, <fcc.

" 18. Convents and other religious communi- ties should be periodically inspected by some independent authority with the view of ascertain- ing the general condition of the health of the

inmates and suggesting such sanitary and other measures as may seem necessary."

The Preparation of Behring's Diphtheria Anti-toxin.?(The Lancet, December 1894). The

length of time required for the preparation of this anti toxic serum is a considerable drawback. Until

recently three months were considered necessary, using Roux's method ; but Dr. Klein has shortened the period to between three aud four weeks. The

following is the principle of his method : ?" By a few injections of attenuated living bacilli?the at- nuation is due to the age of the culture?along with their toxin into the horse, this animal is fur- nished with a certain degree of resistance. Next, large quantities of living diphtheria bacilli (minus their toxin), taken from the surface of solid cultures of gradually increasing virulence, are repeatedly injected subcutaneously, so as to allow the bacilli

162 INDIAN MEDICAL GAZETTE [April 1895.

to grow and multiply, and to gradually produce within the body of the animal, as is the case in the natural order of things, the toxin, and ulti- mately the anti-toxin.

"

Every such injection on my plan is followed by a temporary rise of temperature varying between Oti? and 1*8?C., and a local tumour; but there is no suppuration at the seat of inoculation. As soon as one such tumour has disappeared a new injection is made, as stated above, with large quantities of living bacilli scraped from the sur- face of solid media (agar and gelatine). By the third week the animal will bear the scrapings from the surface of two whole agar cultures of virulent character. In the case ot one horse I, by this method, obtained anti-toxic serum in 28 days, in another horse in 26 days, from the date of" the first injection. If after the first bleeding of the horse it be again twice or thrice injected with virulent living bacilli (taken from the sur- face cultures), the further serum obtained from such horse possesses even increased antitoxic

power." Surgn.-Capt., D. M. Moir, m.a., m.b-