ruary. Osler's ability, both as a medical man and as an author, is so well recognized that it would seem like carping to take exception to a simple matter of style as we do. But this very ability renders more flagrant the fault. His first paragraph in this article begins: "You all know pulmonary tuberculosis. Many of you know it too well." And this apparently addressed to an assemblage of physicians, although the occasion of the address was not specified in the journal! And this, too, in the present day, when there is such a straining after knowledge concerning tuberculosis, when thousands of the most eminent members of the medical profession are lamenting the defects of their known knowledge, when many more thousands are far more deficient, and hundreds of thousands of people are dying from a preventable and curable disease because of ignorance!

We are acquainted with men eminent in the field of phthisiology; yet have we to see the first to bemoan his excessive knowledge. Possibly we do not know the names of those to whom Osler's mind refers, and we beg that they be made known so that the profession of not only America, but the whole civilized world may emblazon their names on tablets of gold, may pay due homage to their superior knowledge of this subject. Then, after such homage, will we rise in our might and smite them hip and thigh for their egregious selfishness in retaining to themselves the substance of their mighty ommiscience.

THE PHYSICIAN'S DUTY TO A PATIENT WITH A COLD.

The question of the early diagnosis of pulmonary tuberculosis still continues to occupy a prominent position it the field of medical literature, as is evidenced by the frequent articles appearing dealing with that subject. The necessity for the earliest possible diagnosis of the disease is intoned, the various aids to render this more easy and more certain are detailed, and attempts to place the responsibility of failures are not lacking.

It is not the case that the physician is principally responsible in by far the majority of instances. On account of the extremely insidious development of the disease, the patient fails to see the necessity for, or even the advisability of, seeking medical aid until late in its development. Not infrequently is the physician visited for relief from what seems to be a simple cold or a mild attack of bronchitis, and, if the physician suggests an examination, the patient is not convinced of its necessity and does not wish to incur the extra expense. Frequently he comes again and again for the same, as it seems to him, slight ailment, and gradually he loses faith in the physician because of failure to receive relief.

In many of these cases it is true that the physician is not without blame. Still, he can not insist upon an examination in such a case at the first visit. However, it is his duty both to his patient and to himself to explain the possibility of an affection more serious than suspected being concealed beneath

symptoms, treatment, and course of five of his personal cases. The treatment. should be directed towards quieting the nervous irritability and sustaining the vital forces. Nutrient enemeta, chloral by rectum, and hypodermics of morphine and strychnine will be indicated. The administration per os of bicarbonate of soda, sometimes in enormous doses, with a view to rendering neutral the acid hypersecretion of the stomach will at times be strikingly effective, but may again at other times entirely fail.

PRIMARY SARCOMA OF THE STOMACH.

Sipher (American Medicine, December 31, 1904), reports three cases of primary sarcoma of the stomach, and records five additional cases collected from the literature. These eight cases have all occurred in the last two years, and are reported with a view to completing the list of cases of "Primary Sarcoma of the Esophagus and Stomach" compiled and recorded by Dr. W. T. Howard, Jr., in the Journal of the American Medical Association, February 8, 1902. The addition of these cases to the list of sixty-one reported by Dr. Howard will give a total of sixty-nine cases recorded.

TRIC ULCER.

Murdoch (Medical News, October 8, 1904), reports additional cases in which he has found orthoform of great value in differentiating gastric ulcer from other painful affections of the epigastruim. The usefulness of orthoform in establishing a correct diagnosis of gastric pain of uncertain origin rests upon the fact that the remedy will not anesthetize nerve endings when they are protected by skin or mucous membrane. If the administration of orthoform in these cases is followed by relief from pain, the conclusion is drawn that the pain so relieved must originate from a surface from which the mucous membrane has been removed. A dose of eight grains of orthoform will often within half an hour relieve a most intense pain caused by ulcer of the stomach. Of the three cases reported, appendicitis had been suspected in one; in the other the diagnosis had been biliary colic, and in the third case the diagnosis of gastritis had been made by two physicians. The correct diagnosis of gastric ulcer was established in each case by the administration of orthoform.

NERVE BLOCKING TO PREVENT AMPU

TATION SHOCK.

Hermann B. Gessner, in American Medicine, September 24, 1904, presents

the subject of "Nerve Blocking to Prevent Amputation Shock, with Illustrative Reports of Two Thigh Amputations."

One case was a tuberculosis of the knee, and the other a chondro-sarcoma of the upper end of the tibia.

In both cases amputation was done at about the middle of the thigh. In making the flaps, the great sciatic, and the internal saphenous nerves were identified, isolated, and oedematized with cocaine, in the first case a two per cent., and in the second a one per cent. The nerves were then divided through this oedematized region, and the amputation was in other respects as usual.

Both case recovered very satisfactorily with practically no shock, which result contrasted strongly with his last amputation at this site, which ended. fatally through shock.

Gessner does not claim that these cases are sufficient to establish a principle, but presents them in corroboration of the previous work of Geo. W. Crile (Problems Relating to Surgical Operations), and Harvey Cushing (Annals of Surgery, September, 1904).

He also quotes the following from Cushing:

1. By common usage the term shock has come to represent a peculiar state of depression of the normal activities of the central nervous system. Such a condition is ordinarily brought about by traumatism of one sort or another to peripheral afferent nerves. In order to produce shock the impulse resulting from this traumatism must have acted reflexly upon the vaso-motor mechanism in the medulla in such a way as to occasion a marked fall in blood pressure. This diminution in arterial tension is the most characteristic symptom of shock.

2. Under ordinary circumstances injuries of only moderate severity to peripheral nerves cause a rise in blood pressure. If, on the other hand, these injuries are extensive or frequently repeated, or if they are complicated with certain primary or secondary anemias, they are commonly productive of a fall in blood pressure, indicating a state of shock. Consequently, shock need not be occasioned, even in the most extensive surgical procedures on the extremities, provided due regard is given perfect hemostasis. In operations of considerable magnitude, however, during which the division of many nerves becomes necessary, or in operating upon such traumatic cases as have been already complicated by extensive injuries to peripheral sensory nerves, so-called operative shock is rarely avoided. When, therefore, any condition is existant which predisposes to shock, such as loss of blood, prolonged anesthesia, etc., or when a certain degree of shock is already present before operation, a special risk is attendant upon the division of important sensory nerve trunks.

3. Cocaine injection into a trunk effectually blocks the transmission of all centripital or sensory impulses. Cocainization, therefore, of trunks of nerves central to the proposed site of their division in a major amputation prevents the conduction of these impulses resulting from the traumatic insult which otherwise, by acting reflexly through the medullary centers, might become the chief factors in the production of shock.

This sane method of preventing shock has been employed in amputa

tions of the upper extremity by injection of the brachial plexus by Lund, Powers and others.

The above use of the cocaine injection is of course radically different from that in which the object is anesthesia of the distal parts.

AMPUTATION OF THE LEG UNDER LOCAL ANESTHESIA.

A case of amputation of the leg after infiltration and regional anesthesia is reported by John H. Gibbon, in The Philadelphia Medical Journal, May 2, 1903. His case was a male 50 years of age, with an advanced tubercular disease of the ankle joint and the tarsus. Because of the patient's age, his general condition, and the extent of the disease, it was decided to amputate, and this under regional anesthesia.

Fifteen minutes before operation, he was given, by hypodermic injection, morphine, gr. 1/4, and atropine gr.

1/150. The sciatic and anterior crural nerves were exposed by infiltration anesthesia with Schleich's solution, and these nerves injected with a 1 per cent. cocaine solution (regional anesthesia). Distal anesthesia was not complete for about 8 minutes, but analgesia was perfect, as was shown by a painless incision into the joint.

Incision of the soft parts at the middle third of the leg did not cause any interruption or hesitation in the conversation of the patient, who was not aware that the amputation was in progress till he heard the sawing of the bone. Recovery was uneventful, and a recent examination revealed no late effects. The above method of producing anesthesia should be limited to cases in which general anesthesia is contra-indicated. The method must be studied carefully in many small operations before it should be employed in the more extensive ones.

A bill has been introduced into the Colorado legislature by Senator B. L. Jefferson, M. D., for an amendment to the state constitution which will permit the regents of the State University to establish departments of medicine, dentistry, and pharmacy in Denver. A number of years ago the medical department of the State University was located in Denver, but as a result of a suit brought by the University of Denver it was compelled to be removed to Boulder. This location has never been satisfactory to the authorities of the State University.

It is reported that the Des Moines City Library has set apart a reading room for consumptives. In this room is provided recent literature relating to the prevention, treatment and cure of the disease. This step tends to secure the separation of consumptives from other frequenters of the library and also furnishes material for the education of those vitally interested in the disease, viz., its victims. It is to be hoped that the experiment may prove successful and the example set found advisable to be followed by other libraries.