are formed by association of cells. The antithesis of the individual and social instincts, or of egoism and altruism, increases in the animal kingdom in proportion to the development of psychic activity and social life. In the higher social animals definite customs arise in this way, and these become rights and duties when obedience to them is demanded by the society (herd, flock, tribe, people) and the breach of them punished. Savage races at the lowest stage of human development, the stage which knows not religion, are not differently related to their cus. toms than are the higher social animals. The higher savages, however, develop religious ideals, combine their superstitious practices (fetichism and animism) with ethical principles and transform their empirical moral laws into religious commands. Among barbaric, and more particularly among nearly civilized, races definite moral laws are formed by the association of hereditary religious, moral and legal ideas. In the civilized races the Church formulates the religious commands, and jurisprudence the legal commands, in more definitely binding forms; the advancing mind remains, however, subservient in many respects to Church and State. Ultimately, in the higher civilized natione pure reason gains more and more influence on practical life and thrusts back the authority of tradition; on the basis of biological knowledge a rational or monistic ethic is developed.

After the years of life spend their forces created in the beginning of his existence, man thinks perhaps, as senility approaches, that he is "losing ground" physically and nervously. He could not lose much mentally under any circumstances, there is very little margin in that direction. Indifference towards everything; no energy, hollowness of life promise; brutality of God or Nature, or the law of things-motion! motion! motion! -no feeling but that of irritation for or towards whoever maintains that Free-Will exists the foolwriters on the subject in the daily press; the treachery of the Creator revealed in the organic land, and briefly, beautifully and pathetically illustrated by the fable of Eden; high ideals unattainable-all these become reality to him. Nature allows the forming of an, or the ideal and thein most ingeniously, and with evident plan obstructs the path and paralyses the effort. No calm observer, it would seem, would deny this.

The multimillionaire, the great orator, the great miser, the great spendthrift, the great philanthropist, the great criminal, the great soldier, the great thinker, are now products -they are results of accidental conjunctions as individuals; though types may be deemed

products of persistent limitations. I do not not see how this can be successfully denied; and until it can be successfully denied it must be admitted that there is no Freewill.

As Haeckel points out: "Prominent teachers of the Christian Church, like the father of the Church, Augustine and the reformer Calvin, denied the freedom of the will, as precisely, as the best known leaders of pure materialism like Holbach in the eighteenth and Büchner in the nineteenth century" (Welträthsel, p. 55, close of chapter vii).

WHEN TO BLEED.-Sewall considers the

disappearance of the second cardiac sound at the apex a distinct indication for phlebeotomy.

NERVOUS DYSPEPSIA OF OLD AGE.-Charcot and Loomis recommend preparations of zinc, arsenic and phosphorus; also "a little wine for the stomach's sake.

Hollander's

LUPUS ERYTHEMATOSUS. method of treating lupus erythematosus (Critic and Guide), consists in the administration of large doses of quinin and the application of tincture of iodin to the lesions. The results are said to be very satisfactory.

XEROSTOMA.-Anders directs to treat dry mouth by attention to systemic disease or iodid and pilocarpin (gr. 1-20) in gelation debility, and by small doses of potassium lamellae or in lozenge form, allowed to dissolve in the mouth with the aid of a sip of water. The galvanic current should be tried in cases of obscure or centric origin.

QUININ IN PNEUMONIA.-A. S. v. Mansfelde, Ashland, Neb. (Jour. A. M. A., March 17), calls attention to the recommendation of the use of large doses of quinin in croupous pneumonia by Prof. Theodore Juergenson in v. Ziemssen's "Cyclopedia of the Practice of Medicine," vol. v, p. 165, and says that he has used just this treatment for the past thirty years. In this connection, he remarks that Dr. Galbraith's publication "demonstrates that nihilism in the use of individual drugs simply means lack of knowledge of their proper uses, with the consequent reliance on proprietary mixtures, which only too often are void of substance and consequently of action." Is it not a pity, he asks, that such masterly works as Ziemssen's Cyclopedia are so much ignored at the present day?

RUPTURE OF THE UTERUS.*

T. O. HARDESTY, M. D.

JACKSONVILLE, ILL.

THE accident, though it is not met with very often, is one of the most serious with which the obstetrician comes in contact. It usually occurs during labor, although there may be a spontaneous rupture during preg nancy. A spontaneous rupture may be caused by rudimentary uterus, or some malformation, or may be due to a weakening of the uterine wall from some previous surgical operation, or faulty hypertrophy of uterine tissue. For this form of rupture suffice to say that the rupture nearly always occurs in the upper part of the uterus, usually near the fundus. Rupture of the uterus during labor is not met with so often, but when it does occur it is a most serious complication. The child is nearly always lost and often the mother.

The causes of uterine rupture are many. The peculiar arrangements of the uterine muscular tissue adds to the cause. The lower portion or neck forms a contracting ring. The upper part or fundus by its contraction serves to expel the child. This contraction must be sufficient to expand or dilate this contracting outlet over the presenting part of the child, and any obstacle or pathological condition that prevents the dilatation and passage of the child stimulates the fundus to more forcible contraction, which may cause thinning and stretching, and finally rupture. As further causes may be named, transverse presentation, pelvic deformities, very large fetus, injudicious use of ergot, weakening of the uterine walls by too frequent child-bearing, malpositions of uterus, unskillful manipulation during version and forceps operation, or other mechanical injury and inflammatory changes in uterine tissue.

The lower segments of uterus are most liable to rupture during labor. If very near the cervix the rent is transverse, if higher up may be oblique or lengthwise.

The general cause for rupture in different places is stretching of the uterine wall over some protruding angular part, as the head, breech, knee or elbow.

Ruptures may be partial or complete. If partial the uterine muscular wall is ruptured, but not the peritoneal covering. In a complete rupture the entire covering of uterus with the uterine tissue is ruptured and the contents of uterus is discharged, wholly or partially into the peritoneal cavity. These ruptures may not follow the course given, but

Read at the February meeting of the Medical Club of Jacksonville.

may be irregular and involve the entire cervix and extend into the vagina.

The symptoms of rupture of uterus vary considerably, although rupture may occur suddenly and without warning, there are generally some premonitory symptoms, that point to a serious condition. Some of the causes which have been assigned given are indicative of impending danger. The contraction of womb may be tremendous with no descent the round ligaments become tense and may be felt, the vagina tense and apparently elongated and narrow. When there is

an actual rupture, the typical symptoms are: suddenly at the height of a strong uterine contraction, there is a sharp lancinating pain in the hypogastric region, with some interrogation or exclamation by the patient, a noise caused by giving away of tissue may be audible to those near, suddenly and simultaneous there is absolute cessation of uterine contraction, and with this there is at once marked relief feeling of the flow of blood externally or internally. Hemorrhage may be very severe or light, or may be internally and concealed. Shortly after the occurrence of rupture there is violent shock and collapse, as indicated by pallor, pulse loose tone, frequent and feeble, cold extremities, hurried, shallow respiration, gasping, pupils dilated, disturbance of vision, vomiting, dizziness, fainting and chilliness. There may be copious sweating and the patient pass into unconsciousness. Diagnosis of those cases which occur gradually and are incomplete may be very difficult, but in the sudden variety, if they occur under your observation the diagnosis is very easy, and once having been seen is easily recognized and never forgotten.

On vaginal examination the presenting part has gone or materially changed, the rent may be found. There is lack of tone to the parts. and great sensitiveness.

The

On inspection and palpation, the contour of abdomen is not regular as before. parts are relaxed, and the physician may be able to palpate a knee, elbow, head or breech, protruding into peritoneal cavity, the uterus may be recognized separate from child.

The prognosis as to the child is almost always fatal. Yet under certain favorable condition the child might be saved. For the mother the prognosis is much better. The first eminent danger is from hemorrhage, which may occur at once or within a few hours, or it may be delayed for one or two days.

The second danger, and by no means trivial, is infection. In this the prognosis depends on the kind of infection, the condition of patient, the situation of rupture, and surroundings of patient, but even under the best con

ditions obtainable, the mortality of the cases reported is very great, being from 30 to 50%, and no doubt there are many cases never reported that would make the percentage much greater.

With this paper I wish to report two cases of uterine rupture that occurred within a period of ten years practice in an experience of 520 obstetrical cases.

CASE I. Mrs. R., age 30; height 5 feet 4 inches; weight 110 pounds; German, three children, last child two years old. Previous pregnancies and labors normal. History of this pregnancy normal. Labor began at full term on Wednesday. Dr. A. was called. As soon as the os began to dilate hemorrhage began and increased with dilatation.

There

was a palcenta previa with central implantation. Nothing was done for this condition. The pains were normal, but the hemorrhage continued severe. Early Thursday morning the placenta passed the cervix and was removed from the vagina. There was a cross presentation with left arm down and out, firm contraction, with the shoulder impacted in pelvis. Dr. Z. was called in consultation on Thursday, but nothing accomplished, and the case was given up to die. On reaching the case early Friday morning I found woman in collapse, pupils dilated, could not talk or understand; extremities cold, and pulse very feeble. No hemorrhage; no pain. Patient was completely relaxed, and did not complain of pain or sensation. Blood from previous hemorrhage had passed through a feather bed. and mattress and run across the room. I pushed the shoulder up and out of pelvis, replaced the arm and turned child by bipolar version. I then grasped both feet and extracted the child by force, there being no help on part of woman. No hemorrhage followed. In examining the vagina found a piece of muscular tissue three inches long and one inch wide, hanging by a pedicle, and finding no pulsation in it, I clipped it off. Only a little capillary hemorrhage followed. This proved to be a section of the the os with about two inches of uterine wall. There was a

transverse rupture of anterior portion extending into vagina. The woman rallied slightly from the shock, but died ten hours later.

CASE II. Mrs. B.; height 5 feet 5 inches; weight 150; age 35. Six children. Family history good, surroundings good. Previous labor normal. Was unexpectedly called into case. Labor had been in progress four hours. On inspection I found child with long diameter at right angles to body of mother, head to left. Pains normal and about five minutes apart. In vaginal examination found bag of water had ruptured.

The parts were relaxed, and the os fully dilated, and the child's right hand was presenting at external genitals. With shoulder impacted in pelvis, and the child was alive. Chloroform was at once administered until all muscles were relaxed. The hand and arm was replaced, the shoulder disengaged from pelvis and child turned by bipolar version until the head was presenting O. R. A. The head was flexed and held in position until the womb contracted and held it so. Labor continued and the pains grew stronger and position of child was good. The head was

entering superior strait of pelvis, and the pains were very hard and becoming expulsive. About two hours after turning the child, during an exceedingly strong pain. Apparently something gave way and the woman suddenly relaxed and exclaimed: "something broke. There is something flowing." On examination I found about one quart fresh blood in the bed. Head still in superWoman showed great

The

ior strait, but loose. exhaustion and collapse. There was no signs of muscular contraction. An angular protuberance appeared between umbilicus and pubes.apparently an elbow. I suspected rupture, and consultation was summoned, and the diagnosis confirmed. Forceps were applied and child delivered two hours after rupture. There was no sign of uterine contraction or aid from women in delivering. child weighed twelve pounds and was dead. There was no signs of life in the child after the rupture. The placenta followed the child. There was no more hemorrhage and womb immediately contracted as in normal labor. The woman was carefully cared for and soon recovered from shock. Ten hours later the 5000 with a return flow syringe in order that womb was irrigated with Hgel, solution 1the uterus might not be disturbed. There was a mild infection following in this case, lower part in the pelvis. involving a part of peritoneum, especially the Paralysis of bladder followed lasting three weeks. All sympgained her former health. toms improved, and the patient finally reSix years have elapsed, but there has been no subsequent

pregnancy.

VERTIGO FROM BRAIN TUMORS.-Peterson employs antipyrin, cannabis indica, morphin; potassium iodid, mercury or mixed treatment for syphilitic growths.

IN the presence of a breast infection that fails to heal within a reasonable time after appropriate incision and dressings, it is well to think of local tuberculosis.

FEVER; WHAT IT IS, AND THE INDICATIONS FOR TREATMENT.*

C. A. BOICE, M. D.

WASHINGTON, IOWA.

THE advertising pages, and frequently the reading pages, of practically all of our medical periodicals are replete with advertisements and laudatory notices of some old drug in a new dress. The change in name has apparently endowed it with wonderful powers. The nanie is high sounding, easily remembered and frequently meaningless.

This or that drug is recommended for fever, no attention whatever is given to the cause of the fever or to the condition of the patient. We are instructed to give this remedy, the fever will be immediately reduced, the heart will not be depressed (?), and all will be well with the patient. Will it?

We must draw one of two conclusions from such manner of treatment. Either that fever is a disease per se, and to be so treated; or that there are many, very many medical men who are willing to take any advertiser's word as their law of procedure and treat accordingly. Such men may be doctors, but they are not physicians.

There is certainly a call for such drugs else so much money would not be spent in exploiting them. Practicing medicine along such lines is a good thing for the pharmacist, a poor condition for the doctor and a very bad condition for the patient. It is like the blind leading the blind, and the patient falls into the ditch.

Is fever a disease per se and to be so treated, or is it only a symptom of some other disease? If only a symptom should it be treated empirically? If we may, let us learn what fever is before we treat it.

Gould defines fever as a "systemic disease, or a symptom of disease whose distinctive characteristic is elevation of temperature, accompanied also by quickened circulation, increased katabolism and disturbed secretions."

Aronsohn defines fever as a "result of morbidly exaggerated stimulation or irritation of the heat centres.' What stimulates or irritates them?

Bergel says that the febrile phenomena are not the consequences of the high temperature, but are the direct results of the infective processes.

Fevers have been divided into idiopathic and symptomatic. Idiopathic fever is one whose cause has escaped detection, but because it has not been detected does not

* Read before the second annual meeting of the physicians of the First Councillor District of Iowa at Fairfield, Ia., January 26, 1906.

To my

prove that it may not be found out. mind, the word idiopathic is one of the most unfortunate in our vocabulary. It is such a nice sounding word with which to salve our consciences when we cannot, or are too lazy to make a correct diagnosis. The more we know of morbid physiology the less use we have for such nondescript words. For the purposes of this paper, fever as a symptom only will be considered. Is it scientific or rational to treat the fever without reference to the cause? The most important thing to remember is that we are not treating a disease, but a patient with an ailment.

High temperature is the outward expression of disordered katabolism, rarely should it be treated by direct action, more rarely by direct depressants. We are entirely too careless in regard to applied therapeutics. The trouble is largely with medical colleges. Rare is the college which gives therapeutics a prominent place. Most of them assign to it a very inferior position; some almost entirely ignore it as a branch of medical science. Surgery and obstetrics are so much more spectacular, but are they so practical for every day practice?

The causes of fever may be toxic conditions, infective processes, gastro-intestinal disturbances, heat stroke or purely nervous. The physiology of fever is increased production and elimination of carbon monoxide, increased action of the skin and increased elimination of nitrogen, and disappearance of glycogen from the liver.

High temperature is the result of an attempt on the part of the system to throw off the disturbing factor. There is an increased leucocytosis. Why not help, instead of hinder?

Fever is probably the most valuable guide we have to the severity and progression of the morbid state, and when we unnecessarily depress the hyperpyrexia, we lose sight of our index. The indiscriminate prescribing of the much vaunted antipyretics is to be deplored. Medicine is not a fixed science, and never will be as long as such methods are followed.

It is frequently necessary to prescribe medicines before a positive diagnosis is made, but the case is not rendered any clearer by depression.

Of the various febrifuges the coal tar derivatives are the most popular. Acetanilid, antipyrin, antifebrin and other antis ad nauseum. They reduce fever by direct action on the beat centre, but they do not stop there. They do not in any manner remove the cause of the fever. They stop nitrogenous waste only while their effect lasts. They depress the heart and general nervous sensibility. Con

tined or large doses are serious heart depressants. They are seldom indicated, rarely useful and frequently harmful. Their chief advantage seems to be that they permit the patient to die with a normal temperature. It calls to mind a story of the times when bleeding was the panacea for all ills. A child was freely bled for some slight indisposition and death resulted. The mother was comforted with the advice that her child had died cured anyway. Many such brilliant results have

followed the use of coal tars.

Alcohol and aconite owe their antipyretic action to their property of causing vasomotor dilatation and permitting increased radiation of heat. They require very careful watching and frequently leave the patient in a worse Alcohol lessens shape than before using.

leucocytosis, checks all elimination and disturbs proteid metabolism. Aconite is a powerful cardiac, respiratory and circulatory depressant. It should not be given in typhoid and other asthenic conditions.

Quinine acts as a febrifuge in doses of twenty or thirty grains by retarding oxidation, and thus preventing heat production. It does not act on the cause of the fever unless it be malarial. Quinine also stops nitrogenous waste only while its effect lasts.

Stevens says that "Antipyretics are only indicated when the fever is high enough to be in itself a source of danger. They are all more or less depressing."

Cold sponging has a tonic and stimulant effect; it promotes formation of leucocytes. and assists in overcoming the infection; it quiets nervous excitability, soothes the patient, lessens delirium; restores circulatory equilibrium and promotes rest and sleep.

If the hyperpyrexia is caused by typhoid or other intestinal putrefaction and its resultant autointoxication, clean all infective material out of the alimentary canal and keep it clean, and there will be very little use for antipyretics. If the hyperpyrexia is from retained pus (be it appendical, mastoid, empyema or what not) drain out the pus, sustain the patient and the fever will take care of it. self.

The rational treatment of feverish condi. tions has well been summed up by Dr. I. N. Love:

1. Prompt, potent purgation.

2. Effective action of all eliminating organs.

3. Intelligent nutrition.

4. High temperature and nervousness best controlled by cold sponging and rectal flushing.

5. Rest.

"Study disease not less, but man more"

Salix nigra and saw palmetto will cure many cases of spermatorrhea.

Dr. Phillips praises bryonia in hepatic dyspepsia, with bilious headache and vomiting.

Dr. Tuffier concludes that beyond the age of 50, all acute intestinal obstruction is due, to cancer.

Dr. Rouget says that inhalations of amyl nitrite will relieve hemoptysis when other agents fail.

Beale recommends rest, starvation, tea or coffee, acids, warmth and counter-irritation for migraine.

A curious case of ptyalism.-In one of Shali's cases increased salivation persisted for six months after a single dose of calomel.

FRIEDRICH'S ATAXIA.-A. H. Dodge, Philadelphia (Jour. A. M. A., March 17), reports a case of Friedriech's ataxia with nearly all the typical symptoms except the familiar feature. This, however, is not remarkable as sporadic cases are not rare. The patient's father was an alcoholic. In commenting on the case, Dr. J. H. Lloyd, in whose service the case occurred, speaks of the comparative ease of diagnosis of the condition, and mentions a type of congenital ataxia paraplegia occurring in children, with some spasticity, increased knee jerks and speech disorders, with or without nystagmus. This is sometimes seen in children who have suffered injuries at birth and is then of course in no sense hereditary or familiar.

THE BLOODLESS PHLEBOTOMIST.-The April issue of The Bloodless Phlebotomist contains a grist of interesting original matter, which will appeal to medical men. Among the leading articles are: Proprietary Remedies from the Physician's Standpoint, by W. J. Robinson, Ph.G., M.D., of New York; The Lesson of the Yellow Fever Epidemic, by Daniel Lewis, M. D., LL.D., of New York; Delirium Tremens, by T. D. Crothers, M.D., of Hartford; The Alkaloidal Treatment of Pneumonia, by W. C. Abbott, M.D., of Chicago; Otitis Externa Circumscripta, by Prof. James A. Campbell, M.D., of St. Louis. The Bloodless Phlebotomist occupies a unique position in journalism. It is original, liberal and exceptional. There is no other journal like it. It is not wedded to one idea, nor is it hidebound nor prejudiced. It says what it means and means what it says. The Bloodless Phlebotomist circulates 208,000 copies each issue, reaching practically every English speaking physician on the globe. It is a journal worth cultivating.