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treatment with 1 to Ii pints of normal saline con-taining 5 per cent. glucose given intravenously.To this 100 units of insulin should be added. Theinfusion should be given slowly, at least 30 minutesbeing taken over the process. Thereafter I shouldadvise you to see the patient at least every threehours until you are satisfied that recovery is wellstarted. The indications of improvement which youshould look for are diminution in the hyperpnoea,strengthening and slowing of the pulse, recovery ofconsciousness, and diminution of the ferric chloridereaction in the urine. The further course of treatmentmust depend on your findings. If improved, another20 units of insulin covered by 50 g. of glucose everythree hours for the next 12 hours will probablysuffice to carry the patient on. In severe cases

larger doses of insulin, given intravenously, if thereare indications of failing circulation, are needed.As long as you cover your insulin by glucose, intro-duced orally, subcutaneously, or intravenously, andtake the precaution of satisfying yourself that-

glycosuria is present, the risk of hypoglycsemia neednot worry you. Adequate insulin and adequatefluid are the two great essentials of treatment. I

CHRONIC DIARRHŒA

(DR. ROBERT HUTCHISON)CHRONIC diarrhoea is a symptom and not a disease,

and diagnosis has usually to be made by exclusion.Some form of classification is therefore necessary, andthe following is suggested :-

1. Gastrogenous, due to achlorhydria or to achylia.Why these sometimes lead to diarrhoea is not under-stood ; it is apparently not a question of " gastrichurry nor of the absence of the antiseptic action ofnormal gastric juice. The stools are loose, and mayoccur either after meals or between them ; theycontain undigested connective tissue.

2. Fatty, where the stools contain undigested fat.This variety includes the rare condition congenitalsteatorrhma, in which liquid fat is present ; pancreatic<M<M’Q3<x, due to failure of pancreatic secretion toenter the bowel and in which split fat is present inexcess, as well as undigested muscle-fibres ; cceliaedisease, met with in children and occasionally inadults, and due apparently to a failure of absorptionof fats ; and, lastly, rare cases in which blocking oflacteals-8.g., in tabes mesenterica-also interfereswith fat absorption.

3. Enteritis, a catarrh of the small intestine whichmay arise from various causes-e.g., alcoholism,tuberculosis, and uraemia (eliminative diarrhoea)-butsometimes from unknown causes. The stools are

fluid, and contain bile-stained mucus on microscopicalexamination. They may be offensive from decom-position of proteins (putrefactive diarrhoea), or sourand bubbling from fermentation of carbohydrates(fermentative diarrhoea).

4. CMotMc.&mdash;In this large group the seat of thetrouble is in the colon. One may distinguish thefollowing varieties : (a) catarrhal-a simple catarrhof the bowel-in which the motions tend to occurin the early part of the day (morning diarrhoea) ;(b) ulcerative, due to ulcers in the colon. These maybe either dysenteric or non-dysenteric (ulcerativecolitis) ; (c) obstructive, where the diarrhoea occurs asan "overflow." The obstruction may be due simplyto an accumulation of scybala (spurious diarrhoea)or to non-malignant-e.g., tuberculous--or, far morecommonly, malignant tumours. i

In all cases of chronic diarrhoea the stools are aptto contain visible mucus, and, if ulceration is present, J

blood. Tenesmus is also frequent. The general nutri-tion, however, suffers less than in cases of enteritis.

5. Neurogenic; where the nerve mechanism is aloneat fault. One may distinguish as varieties : (a) reflex,an exaggerated reflex excitability of the bowel. Ifthe motions occur immediately on the taking of foodthe diarrhoea is spoken of as lien teric (b) emotionalor psychogenic, where fear, anxiety, and otheremotional states " fire off " the bowel.

DIAGNOSIS AND TREATMENT

The differential diagnosis of these varieties involvesthe taking of a careful history ; thorough physicalexamination, both abdominal and general; an

inspection of the stools, both by the naked eye andthe microscope ; and a digital exploration of therectum. In some cases it may also be necessary touse the sigmoidoscope ; to give a test-meal, and to havea chemical analysis of the motions for fat, &c. AnX ray examination after a barium enema is oftenhelpful. In spite, however, of the most carefulinvestigation the cause of the diarrhoea frequentlyremains unexplained.

Treatment depends upon the cause, and the routineuse of astringents is to be avoided. Diet is of thefirst importance, but over-strict dieting is harmful.As a general rule, a low-residue diet is to be chosen,but it must be modified in special cases. Thus, ingastrogenic and in putrefactive diarrhoea meat mustbe restricted ; and in the fatty group, fats ; in thefermentative, carbohydrates. Drugs are of limitedvalue, but hydrochloric acid is a specific in the

gastrogenous group, moderate doses usually sufficing.Calcium carbonate and phosphate are of use inenteritis, especially in the fermentative form, whilstbromides often control neurogenic diarrhoea. Opium .

should be used sparingly, and chiefly for pain andtenesmus. As a means of " locking up " the bowelin the psychogenic cases it is liable to abuse, but is.of great help in small doses before meals in the lienterictype. Emetine should be given in the dysentericgroup of amcebic origin, and castor oil in

"

spurious "

diarrhoea. Pancreatic preparations are indicatedwhen unsplit fat is present in the motions in excess.Lavage of the bowel can easily be overdone, but ishelpful to a limited extent in simple ulcerative colitis,normal saline being probably as useful as astringents.Vaccines are generally useless. Surgical interventionis the only treatment in malignant and tuberculousobstructive diarrhoea. It is also called for in somecases of ulcerative colitis, ileostomy or caecostomybeing the operations of choice.

UTERINE INERTIA

(MR. BRIGHT BANISTER)THE subject of uterine inertia is not pre33atel to

students in a satisfactory way. Inertia is the propertyof matter whereby it retains its state of rest or move-ment in a linear direction unless some outside causeappears to alter it, but the term is commonly used todescribe a motionless body. The classical derivation,however, means " without skill," and in consideringuterine inertia we are considering why the uterus isacting without skill, not why it is failing to act at all.

It is misleading to talk of primary and secondaryuterine inertia, for the two types are diametricallyopposed, and are not two phases of the same condition.In the so-called primary type uterine action is sluggishand irregular from the outset of labour, while in thesecondary type the uterus is exhausted after havingdone its best. Treatment in the first type aims atimproving the action of the uterus ; in the second

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type rest is the only treatment which is of value, and Iany attempt to make the uterus empty itself is

dangerous.Many factors may be involved in the production

of disorderly action of the uterus, as found in thefirst type. It may result from some mechanicalabnormality of the baby ; in cases of occipito-posterior presentation, for example, the uterus seldomacts quite as it should. The contractions are shortand painful during the first stage and are felt in frontinstead of at the back as a rule. Early rupture of themembranes and breech presentations may also produceirregular uterine action. The attendant should con-centrate on treating the abnormality, not the uterus.A second cause of disorderly action is muscular

inefficiency of the uterus. This may be called trueuterine inertia. There are poor, short, not veryuncomfortable contractions, and labour may go onas long as 36 hours without the patient being at allexhausted or, troubled. This type of case is usuallyovertreated ; it is better to leave the sluggish uterusalone. Incoordinate action of the uterine muscle isa third cause. Nowadays it is unfashionable to talkof uterine polarity, and many obstetricians refuse toaccept the idea of a preliminary relaxation of thecervical muscle. Nevertheless, there are some casesin which this relaxation fails to occur, and in whichthe upper part of the uterus is doing its best whilethe lower part resists. Rigidity of the cervix is not agood name for this condition, which is really inco&ouml;r-dinate action of the uterine muscle. A fourth causeof irregular action takes origin from the higher centresand arises as a result of fear. The action of adrenalineupon excised uterine muscle is to stop or diminishcontractions, and the same effect is obtained ifadrenaline is injected during labour. When the patientis frightened large quantities of adrenaline are throwninto the circulation.

In a fifth and final type, uterine inefficiency dependsnot so much on poor uterine action as on a defensivecontraction of the voluntary muscles with each pain.This also occurs in frightened patients. Labourusually progresses normally until the pains begin toget stronger, and then progress is retarded. The

patient contracts all the muscles of her body witheach pain, as though trying to put off the moment ofdelivery. In these patients miraculous results followthe use of some form of anesthesia.In one case of the kind the patient had had one previous

child by breech presentation. During her second labour,her husband was continually popping in and out of theroom and remarking : " I hope to God it’s going to be aboy." He asked his wife repeatedly and minutely how shefelt. The nurse, on the other hand, kept saying :

" I dohope your baby’s all right." When the membranes rupturedthe fluid was brownish, and the nurse exclaimed : " Therenow, look at that ! I must ring up the doctor at once."By this time the patient was in terror lest she was going tohave a dead baby, and subconsciously she was doing allshe could to postpone delivery by contracting up hermuscles. At the end of three hours she was extremely tired,and chloroform was started, being given in small doses.Within 20 minutes-as soon, in fact, as the voluntarymuscles were relaxed-the living child was born.

The recognition of the various types of uterineinertia begins with antenatal care. Not only themechanical conditions present but the patient’s

general health must be considered. It is worth whiletrying to find out what the patient is feeling abouther confinement, but she is often reserved and at firstsight she does not appear to be worried. Completevaginal examination should be delayed until the lastfortnight of pregnancy ; a vaginal examination is nopart of antenatal care during the first half of preg-nancy, and those who make one should have a definitereason. At an examination made during the last

week or two of pregnancy it is possible to recognise-those cases which are going to have disorderly actionowing to resistance of the lower part of the uterus.If the vagina is not well lubricated, if the vaginal’walls do not readily admit the examining finger andthe patient experiences discomfort, there is likely to-be difficulty in labour, more especially if the cervix,feels as though it has a core of solid rubber.

During labour itself the attendant should be ableto distinguish between delay due to muscular incoor-dination and delay due to nervous inhibition of pains.The patient in whom the musculature is not equal to-its job may be in labour for a long time withoutsuffering much. She is able to potter about the room,and is untroubled about herself ; if she is given a hotbath and an enema the uterus is often stimulatedinto action, and she does well. The patient of the-second type has short, sharp, irregular pains withoutmuch progress being made. She wants to go to bed..If- this type of patient is given enemas and bathsher fear will be stimulated and no good will be done.When the patient is obsessed with fear, and is showinga defensive contraction of all her muscles at everypain, some method akin to twilight sleep givesexcellent results. But the action of the drug usedmust be supported by a tranquil environment-bypulling down the blinds and by keeping people out ofthe room. In the late stage of labour, chloroform.anaesthesia combined with an injection of pituitrincan be given, but must be used carefully. Chloral,given earlier, is likely to have one of two types ofaction. After a dose of grs. 30, one patient will go,to sleep for some hours and then wake and do well ;.

another will suddenly deliver herself in about 20’minutes, the reason being, of course, that the firstwoman is of the flaccid type who needs rest, whilethe second has spasm of some part of the uterinemuscle which is relaxed by the drug. The uterus isat last able to do its best, and out comes the baby.Our attitude to our patients should reflect that ofKing Henry towards his soldiers before the battle,and, slightly modified, the lines might run :0 God of battles! Steel my patients’ hearts ;Possess them not with fear; take from them nowThe sense of reckoning, if the opposed hoursPluck their hearts from them."

THE UNDEPENDABLE KNEE(MR. ROBERT MILNE)

FoR the patient, a knee has not recovered from an.injury until he feels he can depend upon it. The kneeshould be capable of extending until the leg is straightand bending until the calf touches the hamstrings.,There should be no lateral movement when the knee isstraight, but when the knee is bent it should be possibleto rotate the tibia slightly on the femur. When thelegs are straight, moreover, there should be no,

difference between the quadriceps muscles on the twosides. The quadriceps is the most important factor-in making a knee stable.

Since the advent of the camera and the einemato--

graph it has become possible to analyse the mechanismof walking. When the right foot is on the ground andthe left foot in the act of passing it, the right kneeis seen to be, not straight, but slightly bent. It onlystraightens when the left foot reaches the ground andit becomes necessary to push off with the right footto give the body its forward impetus. The anglewhich the foremost knee makes in walking is about165&deg; ; if there was no muscular action to maintainthis angle the knee would collapse. Text-books of’anatomy state that the purpose of the quadriceps isto straighten the knee, and though it is true that it,