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4. Two tenacula, with hooks in a line with the handle; two others, with hooks at a right angle to the handle; the diameter of the curves in the hooks inch. Those with hooks at right angles are employed for transfixing and holding the trachea when it is to be opened.
5. Two grooved directors, one with the end smaller and more pointed than that of the other.
6. A common artery forceps, and a forceps with fine teeth. 7. A spring-hook, employed by oculists in separating the eyelids. This holds open the edges of the wound.
8. A tracheotomy-tube, consisting of two concentric cylinders, described above.
9. Pigeon's quills. These are important for removing mucopus and fibrinous shreds from the trachea and bronchial tubes. An instance has come to my knowledge in which the physician who assumed charge of a case after tracheotomy attempted to use for this purpose a small piece of sponge held by forceps. He unfortunately loosened his hold, the sponge was drawn in with inspiration, and immediate death by suffocation resulted. This would not have happened with the pigeon's quill.
Dr. Lange does not stitch the wound by the side of the canula, but, leaving it open, dusts iodoform over it, and applies over the iodoform two thicknesses of linen soaked in a bichloride-of-mercury solution, one part to two thousand, and notched so as to surround the canula and pass under the plate. The linen is covered with India-rubber gauze, and is moistened every hour with the bichloride solution.
DR. J. P. GARRISH, of New York County.-Croup is one of the diseases regarding which we always feel an uneasiness when called to see a patient suffering from symptoms suggesting this affection; and I desire, therefore, to say a word concerning treatment. During the past three years, I have treated croup success
fully, other remedies having failed, by administering minute doses of the bichloride of mercury. I give, of a solution of one grain of the bichloride in an ounce of water, five drops every hour. I have also found turpentine of benefit placed over the abdomen.
DR. THOMAS F. ROCHESTER.-I suppose that almost every one has tried nearly every remedy proposed for the treatment of diphtheria, and all have been pleased more or less with their degree of success. I remember very well two cases of diphtheria in children in which recovery took place, no other treatment being adopted than lime-water inhalations, given every five minutes for forty-eight hours or more. I believe it was the constant inhalation of lime-water from the steam atomizer that relieved these children. But after a while, lime-water seemed to fail in my hands. Among the many remedies which are constantly being suggested, there is one which has lately been brought to my attention, with the effects of which I have been well satisfied; but whether or not it will prove of wide benefit, I am not yet able to say. A gentleman has stated in one of the recent issues of a medical journal, that he has lost fear of diphtheria since he has employed calomel and iodoform. I have used calomel a good deal, and have often been disappointed in its effects; but the suggestion of the use of iodoform seems to have a good reason back of it. The first case in which I employed iodoform was that of a child, twelve months of age, suffering from measles complicated by diphtheritic croup. The drug was applied with a camel's-hair pencil, and, although the child died, I was impressed by the fact that no unpleasant manifestations followed the use of the iodoform, which was employed in its pure state. Very soon after, I was called to a family in which one child had already died of diphtheria, and another, a strong girl, eight years of age, presented a large diphtheritic exudation upon the fauces, with slight croupy symptoms. I directed a nutritious diet and stimulants, and made a mixture of half an ounce of iodoform with one ounce of bismuth, which was applied thoroughly by insufflation every two hours. The child made a good recovery. No toxic effects were produced.
DR. A. F. CARROLL, of Richmond County.-I do not think that the danger from diphtheria is always to be measured by the extent of the exudation. It has doubtless occurred to all to see cases in which death supervened shortly after the establishment of
the disease, and in which the exudation was but trifling in quantity. On the other hand, all have probably seen cases in which there was extensive pseudo-membrane and comparatively little constitutional disturbance.
Another point to which I wish to refer is the relation which seems to exist between scarlet fever and diphtheria. It is common for diphtheria to be developed in connection with scarlet fever; but it is very rare for scarlet fever to follow diphtheria. About three years ago, I attended a child who went through a severe attack of diphtheria, and, after eight or nine days, the symptoms subsided. Then, however, the temperature suddenly rose, and, within twenty-four hours, the eruption of scarlet fever appeared and the child died. Of course it had been isolated during the course of the diphtheria.
DR. E. M. MOORE.-All physicians desire, as soon as laryngeal complications develop in the course of diphtheria, to be able to employ some agent by which the pseudo-membrane can be dissolved; and generally an alkaline solution is employed, lime-water having first been recommended, I believe, by a German writer. A great many years ago, I had a case of marked diphtheria, and placed a tube containing the false membrane in a strong solution of bicarbonate of soda. Much to my satisfaction, the membrane was completely dissolved. I was then impressed with the idea that the best plan of treating diphtheria was to use locally a saturated solution of bicarbonate of soda. I first tried to employ it by inhalation with the atmosphere; but, when used in this way, the quantity of the drug which came in contact with the affected part amounted practically to nothing. Later, a friend suggested the employment of a bottle with two tubes passed through the cork, one extending nearly to the bottom of the bottle, and having attached to it a Davidson's syringe, by which it was possible to blow the powder to a considerable distance. At this time there were three children suffering from diphtheria in one family, algid symptoms having developed; and, under my son's supervision, the father of the children employed this method of bringing the bicarbonate of soda in contact with the air-passages for five minutes every hour during the entire twenty-four hours, and the result was that all three of the patients recovered. The children would cry violently during the process, and, as a result of
the deep inhalations while crying, the powder was brought in contact with the false membrane throughout its full extent. In these cases, the patients had symptoms indicating the presence of pseudomembrane in the larynx. The important point in this method of treatment is to make a thorough application of the remedy. If this be not done, it can not produce any beneficial results. In some cases I have had sulphur burned in the room. I imagine that few persons have an idea of the quantity of sulphurous acid that patients can thus be made to inhale; and, after a short time, the irritation produced is very slight. I have also made applications of nitrate of silver in such cases.
FOUR SELECTED TYPICAL CASES OF DIABETES MELLITUS NOT BEFORE REPORTED.
By AUSTIN FLINT, JR., M. D., of New York County.
IN May, 1884, I reported fifty cases of diabetes mellitus to the "Section on Practice of Medicine and Materia Medica, of the American Medical Association," and to this report, which is contained in the "Journal of the American Medical Association," July 12, 1884, I refer the Fellows of this Association for full details of the treatment employed. Since this publication, I have had under treatment four cases of diabetes, which are typical in many of their characters, illustrating different conditions of the disease and the effects of treatment in patients of different ages.
The first case, which, for my own convenience, I shall designate as No. LIII, illustrates the difficulties met with in treatment when the disease has been allowed to run its course without restraint for a number of months.
CASE. LIII. The patient was an unmarried woman, twentytwo years of age, rather slight in figure when in health, and of medium height. Her parents are living and in perfect health. The family history failed to show any hereditary tendency to this or to any other disease. When in health, the patient weighed 140 pounds. This was the weight about three years before she came under my observation. As far as I can judge from the history of the case, the disease must have existed for two years, or perhaps longer. In January, 1884, the patient had lost about twenty pounds in weight, had excessive urination, an abnormally great appetite