by the deep urethral injection of a solution of protargol or nitrate of silver, gr. xx to 3j; or by a curettement of the uterus or the removal of a diseased ovary; or by the relief of a mastoid disease by operation.

The entrance of septic infection through the respiratory tract may be combatted by the use of antiseptics as boric acid, lactic acid, subsulphate of iron, etc.

Intestinal antisepsis may be secured by the use of calomel, salol, betanaphthol, ichthalbin, etc.

In grave cases of septicemia, excellent results may sometimes be secured, and almost always temporary improvement, by venesection and the infusion of normal saline solution.

It is a matter of common observation that alcohol does not readily produce toxic effects in septicemia. It is supposed to increase the number of leukocytes and to neutralize toxins. Large quantities may be given best in the form of whisky or brandy.

Quinin is an old empyric remedy, which reliable men have used with good results. The writer has not seen any benefit from its use in septicemia. It may possibly prove useful in some cases through neutralizing toxins. The beneficial results obtained by the use of the salicylates, and the preparations of iodin, mercury, bromin, and arsenic, may be at least largely attributed to the neutralization of toxins.

Most flattering reports have been made by numerous observers as to the remarkably good results following the use of soluble silver, especially in the form of the unguentum Credé administered by inunction. The writer has used the remedy freely in a number of cases but has been unable to corroborate the reports of its value. It seems to be almost, if not absolutely, inert.

Symptomatic treatment. Fever and pain may sometimes be advantageously modified by the judicious use of antipyretics, such as antipyrin, phenacetin, or kryofin; or, in the presence of great weakness, resort may be had to lacophenin. It is usually better to give alcohol or caffein when using these antipyretics. Fever that becomes danger

ously high may be better controled by hydrotherapy, best sponging with cold water. Affections of the heart, joints, meninges, pleura, or peritoneum call for the application of the icebag. Obstinate pain and sleeplessness demand the use of opium.

If this paper stimulates us to study our cases more thoroughly and to recognize more frequently the septic infections, the writer will feel that its mission has been largely accomplished. We will then hear less of those cases that formerly were regarded as malarial or miasmatic and that today masquerade under the rather vague cognomen of the rheumatic diathesis, which is used as a cloak to cover so many obscure or superficially observed affections.

DISCUSSION

Dr J. H. J. Upham, Columbus: Dr Malsbary's paper is certainly a very interesting and exhaustive one. A very important deduction may be drawn from it, one that has greatly impressed me in the use of serums in septic conditions, and that is the prime necessity of an absolute diagnosis of the variety of organism present in the case under treatment. I think that the failure to do this explains a great many of the reported cases of failure, for example, in the use of the antistreptococcus serum, the latter being used when other organisms than the streptococcus were present. I would like to ask Dr Malsbary if, in the cases of puerperal sepsis he mentions, in which no benefit was derived from the use of this serum, cultures were made establishing the presence of the streptococcus ?

I would like to impress upon the members of the profession the great importance of such measures in instances in which the serum treatment is to be employed. It is usually not difficult to recognize a condition of infection; the clinical symptoms alone, a blood examination showing a leukocytosis, absolute or relative, or possibly, as has been recently suggested, the presence of albumose in the urine, etc., all point readily toward sepsis; only the making of cultures, however, from the blood or discharges will demonstrate the variety of the organism causing the trouble. The streptococcus is present in a given case, I believe the treptococcus serum will prove of great benefit, but I

deprecate the looseness in vogue at present in the use of serums as tending to discredit what may prove a very valuable means of treatment.

Dr George E. Malsbary, Cincinnati, closing: The point which the Doctor mentions in reference to the necessity for an accurate diagnosis of the germ present is a very good one. In the cases of puerperal sepsis there was not a pure streptococcus infection, but a mixed infection which would seem to account for the failures in the cases referred to.

The presence of mixed secondary infection probably accounted for the apparent failure of the antistreptococcus serum in the sepsis of phthisis.

The Importance of a Correct Diagnosis
in Gastric Disorders

BY C. L. MUELLER, M. D., WAPAKONETA

In intruding upon your attention my chosen subject, I want to express my thanks for the honor that I am permitted to present to this illustrious assembly of thinking men this paper. I do this with a certain timidity, as I know very well that everybody present knows the importance of a correct diagnosis without my telling him.

I intended to lay before this meeting a case of otitis media which came under my observation during the Spanish war, and which was caused by a fly depositing its eggs in the ear of a soldier from which innumerable maggots emanated causing the otitis. As far as I could learn there is only one similarly produced case of rhinitis on record, but as I was unable to secure the necessary literature in order to prepare such a paper, so that it could be intellectually read before a meeting of this Association, I had to abandon this. I choose then the above subject as I have, during my sixteen years of hospital, steamship and general practice, given gastric diseases more attention than any other field and always liked this field best.

People, we all know, judge the physician according to

his success; and, therefore, it is of the greatest importance that we always make or try to make a careful diagnosis before deciding on the treatment. If we are not entirely sure of our diagnosis, we should not tell the patient anything, nor give him any hope or promise of cure. Allow me to mention a little occurrence which demonstrates that the adage "talking is silver, silence is gold" is in no other profession more important than in ours.

Several years ago, we had in the town in which I have been engaged in the healing art for the past 11 years, a physician who had the basest disregard for all scientific achievements in medicine. Once after a consultation he admitted frankly to me that they were not taught much anatomy, physiology or pathology at the college (he was not an allopath, I want to say right here) but were taught how to treat and cure sick people as this was the only important part in medicine. I did not go into a discussion, as I never knew that a house could be built without a foundation, but at the present time everything seems possible. This physician was a master in the art of silence and no patient could extract a word from him concerning his ailment or his prospects of getting well, and as he combined this art with gentlemanlike manners and exquisite politeness, he had a larger practice than all the other doctors combined, and he was the leading physician for several years. Later his success caused him to start out as a heavily advertised traveling specialist and here, as I later heard, his nontalkativeness was his ruin. I mentioned this little episode to illustrate how wise it is not to say much to a patient, except when we

are sure.

Coming back to my subject, most of the gastric cases. coming to the attention of the general practician are the different forms of acute and chronic gastritis which Ewald divides into the acute stages in simple acute gastritis and sympathic acute gastritis; the chronic stages in chronic glandular gastritis and chronic gastritis with atrophy of gastric mucosa. The symptoms of the acute and chronic gastritis

and their difference are too well known to everybody to be explained here. But the following diseases, gastric carcinoma, gastric ulcer, gastralgia and chronic gastritis present quite frequently similar symptoms which may lead to a wrong diagnosis especially in cases in which the main symptoms are not so plainly developed.

As each of these diseases requires an entirely different treatment, it is of the utmost importance in such cases to make a correct diagnosis, and often it will be necessary to observe patients quite a while in order to ascertain the right opinion before we decide on a definite way of treatment. This is the reason why we should always be very careful and attentive in all gastric disorders which come under our observation.

In cases of acute gastritis in which alarming symptoms prevail, as high fever, severe pain, nausea or the like, the physician is generally careful not to overlook anything; but I mean patients who consult us at our office, making general complaints as occasional or continuous pains, heavy feeling in the epigastric region, irregular movements of the bowels, nervousness, nausea, anorexia and similar symptoms. In such cases we are only too apt to quiet our conscience with the diagnosis of chronic indigestion, to order a diet and to prescribe a digestive remedy of which each doctor has generally one as his individual pet.

In these cases we have to be on our guard, and often lose patients to other physicians because we took it too easy and did not consider the case as carefully as we should have done. The correct diagnosis is possible only after the most complete and careful consideration of all the symptoms and the employment of all the diagnostic resources. No matter how plain a case of this nature looks to us, and how sure we are that it is only a dyspepsia, we should never reach this diagnosis except by the way of excluding the other mentioned diseases, by the differential diagnosis.

First, in such a case we must be on the lookout for a beginning carcinoma, provided the patient is nearly 40 years