to those met with in interstitial nephritis, accentuate the acidosis. In many cases, too, analysis of the feces reveals an inorganic ash content considerably in excess of the normal. pointing to an abnormal excretion of bases thru the intestinal wall, a condition which would serve to diminish the alkali reserve still further. It is not surprising, therefore, that acidosis of an advanced type, in which several of these factors are probably at work, is difficult to control and, especially in children, whose metabolism is less stable than in adults, as is shown by the fact that comparatively small changes in the diet of a diabetic child will often produce very striking results. Thus, Cammidge has seen the addition of a single egg, or a dose of cod liver oil, induce a ketonuria, which rapidly disappeared when the addition was discontinued. In Cammidge's opinion, it is probable that an increase in the alkali reserve is partially responsible for the symptoms met with in pyloric stenosis and infantile tetany, but accurate observations are apparently lacking. It is known that tetany can be induced in animals by injecting alkalies, and Cammidge refers to one case in which tetanic convulsions followed an attempt to treat a diabetic acidosis in an infant by intravenous injections of sodium bicarbonate. Analyses of the blood in the few cases of alkalosis Cammidge has met with in adults have invariably indicated the existence of some ductless gland deficiency, and treatment with appropriate gland preparations, and calcium by the mouth, has brought about improvement.

Insulin Treatment of Diabetes. Major (Kansas Medical Society Journal, June, 1923) regrets that the term "cure" has been applied by the lay press in speaking of insulin. It does not abolish dietary restrictions in a diabetic, altho its use permits the patient to follow a much more liberal diet than would be possible otherwise. It unquestionably permits many severe diabetics "with a progressive course downward" to live in comparatively good health and comfort, instead of dying in coma. It is premature to speak of insulin as a "cure" for diabetes. There is no doubt, however, that it is easily the greatest single advance that has ever been made in the therapy of diabetes mellitus.

Intermittent Treatment of Malaria With Quinine. Remarkable results are reported by Glaessner (Wiener Archiv für Innere Medizin, October 15, 1922) in a series of seventy-seven cases of malaria, in which quinine was administered according to the method of Ochsner. The bowel is emptied with thirty grams of castor oil on the night before the treatment is begun and for twelve days all meat is forbidden, only a soft and fluid diet (preferably lactovegetarian) being allowed. On the two days following the purge, the patient is given 0.15 gram quinine by mouth every two hours, day and night, simultaneously with about 0.25 litre of a hot drink. This course of treatment is then followed by an interval of eight days, when the same course of treatment is repeated.

TREATMENT

Lavage in the Treatment of Vomiting in Infancy. Jackson, in the Archives of Pediatrics for September, 1923, from his experience says that in nineteen difficult feeding cases, in which vomiting was the predominating symptom, the vomiting was checked by lavage and there was an average gain of 1 pound, 12 ounces in the first month. In no case presenting the symptoms outlined was there a failure to check the vomiting.

Massage in Treatment of Affections of the Heart.-General massage, carefully administered, is of great aid to the peripheral circulation, and Graham (Therapeutic Gazette, January, 1924) thinks it lessens the work of the heart, tranquilizes the nervous system and induces sleep in the worst kind of heart disease; and massage of the abdomen often works well as a diuretic and to relieve the stasis of the mesenteric veins and all the other abdominal veins.

Alleviation of Pain in Severe and Fatal Illness. Dr. J. Leonard Corning (N. Y. Med. Jour., Dec. 20, 1922) deprecates the practice of reducing the doses of opium derivatives as the subject of a painful and incurable disease nears the fatal climax. This is done with the idea of prolonging life to the ultimate minute. and in complete forgetfulness of the fact that extreme suffering is quite as capable of hastening the demise of the patient already hopelessly enfeebled as the cardiac depression wrought by large doses of morphine. The better, the more humane, and the scientific procedure no less, is to continue the stimulation of the heart and the administration of the analgesic, augmenting the dose of the latter, should this be necessary, and increasing that of the former as much as may be. By going forward in this way, the period preceding death may be rendered relatively painless, and the practitioner secure in the consciousness that he has exhausted the resources of his art, will have placed himself beyond the haunting sense of duty unfulfilled.

Chronic Bronchitis.-Hawes, in his summing up of his interesting article in the Boston Medical and Surgical Journal, August 2, 1923, states that chronic bronchitis is a definite clinical entity, occasionally primary, but usually second

ary to something else.

Congestion following a weak heart, bronchiectasis, chronic interstitial pneumonitis, are often mistakenly called chronic bronchitis.

Chronic bronchitis may be classified as follows:

Primary chronic bronchitis, due to: (a) Dust or other irritating substances. (b) Gouty bronchitis.

Secondary chronic bronchitis, due to: (a) Chronic infection of the upper respiratory tract. (b) Acute pulmonary infection. (c) Gassing. Mistaken diagnoses.

Treatment depends on finding the cause, removing it if possible and giving proper treatment.

Asthmatic bronchitis is a form of asthma and not a true chronic bronchitis.

Vaccine treatment should be looked upon as a last resort measure. It should never supplant or replace other therapeutic measures, and should be used only after a detailed search for other causes of chronic cough has been made without avail. The chief requisite in the use of vaccines is to see that they do no harm.

Possibilities of Deep X-ray Therapy.-Fricke (Therapeutic Gazette, January, 1924) thinks that the field and effectiveness of high voltage X-ray treatment is as yet an unsolved problem. Success in combating cancer and kindred disorders is claimed by German and French authorities, with such emphasis that a thoro trial of this form of therapy is called for. Up to date it cannot lay claim to being an established success in this country, but results are already sufficiently encouraging to warrant a persistent trial over several years to ascertain its efficiency in the field of malignant neoplasms.

Finally, he concludes: Deep X-ray treatment is a powerful therapeutic agent; its uses and limitations require further years of study. We have tried to compare it impartially with the work of its slightly older sister, radium, as we employ both forms of treatment ourselves. It is an unwieldy tool for much delicate work; it is subject to fluctuation and the dosage is hardly past the experimental stage. To date it seems the inferior form of treatment where a large amount of radium is available, but it shows promise of benefit where only a small store of radium can be used, and it may prove of great value in conjunction with topical applications of radium.

Functional Treatment of Dysmenorrhea.— As a result of his study of the subject, Fritz Ludwig (Schweizerische medizinische Wochenschrift, December 28, 1922) comes to the conclusion that dysmenorrhea should be considered as a disease of the tonus of the uterus; the conditions of contraction and relaxation are more or less affected by the internal secretions. Abnormal changes of contraction and relaxation, as well as continuous spastic contractions in the

uterus, are chiefly responsible for dysmenorrhea. The normal tone of the uterus is kept at a medium level by the various internal secretions, just like the tone in the blood-vessels. Adrenalin sometimes shows a stimulating and sometimes an inhibitory effect in the same organism, and it is therefore a regulator of the tone. A disturbance of the internal secretions (hypophysis, ovary, corpus luteum, adrenal, thyroid glands) consequently lead to dysmenorrheic disorders. Altho organotherapy seems to be indicated it meets with great difficulties in practice. The substances that have an inhibitory effect on the tone are indicated, and of these papaverin (0.04 gm. three to six times) and benzyl benzoate are the best, possibly combined with narcotine, atropine, camphor, uzara, etc. Morphine and codeine are not indicated because of their stimulating effect.

The Vegetative Nervous System and the Heart. So close and important is the connection between the action of the heart and the vegetative nervous system that Babcock (Annals of Clinical Med., January, 1924) says whenever a physician is confronted by the problem of deciding the nature and cause of simple tachycardia on the one hand or attacks of premature or otherwise disordered ventricular systoles he should endeavor to discover whether or not there be some focus of irritation within the abdomen or pelvis which is exciting the action of the sympathetic or parasympathetic (vagal) portion of the nervous system. There may be associated valvular or myocardial disease, but such lesions may not by any means be responsible for the seizures.

In the treatment of these cases it is essential that the cause of the irritation be removed rather than that the heart receive treatment directly. Disease of gall-bladder or appendix, pelvic disease or recal fistula, hemorrhoids, etc., require surgical intervention, while dietary indiscretions, tobacco, tea, coffee, sweets, etc., must be materially reduced or abandoned and in short all done that may in any way contribute to the trouble. Persons with distinct cardiac abnormalities may, in addition to more or less strict physical rest, receive appropriate doses of digitalis, but in most instances this drug is not required. Finally, in neurotic or frightened individuals it is of distinct value to explain the reason for the attacks and to assure them that the palpitation is not dangerous to life. Nevertheless, in those persons whose myocardium is problematical as regards structural integrity persistence of the disorder or its frequent and prolonged recurrence may lead to serious results. Hence, if this aspect of the case be tactfully presented it will generally be found that the patient will readily cooperate in following the doctor's instructions. Never, and this cannot be too strongly emphasized, never should anything be said calculated to put fear into the patient, since as in the instance first cited fright may serve to prolong or intensify the seizures.

Puerperal Sepsis.-Puerperal fever is a general term covering all the conditions of a febrile nature originating from infection of the genital tract.

Smailes (The Ohio State Med. Jour., February, 1924) states that the course of the fever, type of bacteria present, the severity and extent of infection does not change the diagnosis. It may be only of a short duration, as one day, or it may last for weeks.

The disease has existed from the earliest savage races, and is mentioned by Hippocrates as early as 400 B. C. History tells of the early tribes of 1000 B. C. bathing, using aromatic herbs for fumigation of the vulvæ, and bathing the belly with banana wine to cure the disease.

Curative treatment may be boiled down to absolute rest, and aiding Nature, but give Nature the preference and do not try to do too much. A nourishing liquid or semi-solid diet with a cheerful nurse in a pleasant, well-lighted and ventilated room, will do much. Proper doses of ergot and hydrastis are all the drugs needed with the exception of morphine for pain. As to serums and vaccines he has nothing to

say.

Surgical interference is employed only for retained placental tissue, or for localized abscesses, but do not get in too big a hurry for the latter until the abscess is well localized, when drainage should be undertaken.

In conclusion, the author suggests that you keep in love with your work, and be kind, cleanly and patient.

Treat every case as you would have another physician treat your wife or sister. Minimize lacerations by using patience and chloroform, and do not rush your labors with pituitrin and forceps. Keep your hands and instruments and everything that comes in contact with the birth canal absolutely sterile. And we will not be confronted daily with so many haggard-faced women who trace their illness to childbirth, and the death rate from puerperal sepsis in the future will be greatly reduced.

Rickets. Ratnoff (Long Island Journal, July, 1923) discusses the already well-known pathology and symptomotology of rickets and the now accepted etiology, viz., vitamine A deficiency, coupled with lack of solar radiation.

The author quotes the two views of etiology from the chemical side, viz., a phosphorus deficiency rickets and a calcium deficiency rickets, and gives the prescription which is specific, viz., cod liver oil, or some other vitamine A containing animal fat, phosphorus, calcium and ultra-violet radiation, either natural solar radiation or artificial by means of the carbon arc light and the mercury vapor lamp.

He cautions against sunlight without ultraviolet rays when given thru glass and gives the technic of ultra-violet radiation by the lamp method as follows: "Beginning with four minute exposures at a distance of two or three feet the distance is gradually shortened to two feet and the time of exposure lengthened to

half an hour." A marked erythema should cause the treatment to be discontinued until it subsides and the brown pigmentation which appears at about the fourth or fifth treatment becomes very dark by the end of the treatment, but fades after a few weeks. Marked pigmentation during the course of treatment interferes with the penetration of the rays and therefore the results are not satisfactory. The negro is prone to rickets on this account.

The duration of the treatment, according to the writer's experience, should be a month for every year of the child's age, tho some cases are more satisfactory.

The improvement is demonstrable clinically by the improved strength, activity and mentality and normal appearance of the cranial and long bones of the child, the disappearance of laryngospasm, spasmophilia and tetany and the improved muscle tonus and chest expansion. It is demonstrable histologically in vivo by the X-ray, which shows clearly the centers of calcium deposition increasing, as the treatment proceeds, to normal density.

Backache. The source of chronic backache is taken up in detail by Shackleton in the Illinois Medical Journal, July, 1923.

The more chronic types of backache include the ache of constitutional diseases and toxemia, reflex backache, postural backache and backache due to local conditions. Static backache is due to excessive strain and stress on the muscles and ligaments of the back. This occurs in persons who have been confined to bed for several days and in those who have been placed under the influence of an anesthetic. Pain results from overstretching the ligaments which, when unsupported by the muscles, are not strong enough to maintain the normal lumbar curve. Spondylitis deformans is the common postural defect of old age. It is not necessarily due to infection. Habitual labor in an unnatural position causes backache. Compensatory spinal curvature or muscular hypertrophy is frequently seen among laborers. The shortening of an extremity from a fracture, coxa vara, hip disease, or uneven growth is another cause of backache.

Backache follows fevers, tonsillitis, syphilis, influenza, smallpox, tuberculosis, focal infections, metabolic disorders and toxemia due to intestinal absorption. These are difficult to explain except on the basis of a loss of muscle tone.

Reflex backache is due entirely to involvement of the pelvic viscera, the sensations being reflected thru the ganglion and felt as pain in the corresponding somatic segment. As it descends from the intervertebral foramen, the lumbosacral cord passes over the pelvic brim and is therefore subject to the pressure of pelvic or abdominal tumors or organs. Local conditions causing backache may be metastatic, infectious, or traumatic. Myositis is the most common-usually this is caused by direct violence. Tumors of the back which cause backache are usually metastases from a primary

carcinoma of the uterus, prostate, or breast; an X-ray examination is usually essential for the diagnosis.

The chronic infections of the spine are osteoarthritis, osteomyelitis, tuberculosis and syphilis. Osteomyelitis is not a common spinal lesion and is usually metastatic from osteomyelitis of other bones. Tuberculosis of the spine is very common. Syphilis of the spine is a disease of adult life.

Congenital malformations may cause backache. The common malformations include spina binda occulta, segmented sacrum and anomalies of the transverse processes of the fifth lumbar vertebra. Chronic backache may be caused by injuries. Spondylolisthesis or forward dislocation of the fifth lumbar vertebra on the sacrum is a cause of chronic backache. It results usually from the slipping and twisting of the body during the carrying of a heavy load.

Sacro-iliac subluxations are static and traumatic In cases of the traumatic group there is a definite history of direct or indirect trauma, such as a twist or a fall on the feet or buttocks.

Compression fractures are fairly common. They may become chronic because undiagnosed. X-ray examination in the oblique, the anterioposterior, and the lateral positions will aid in the diagnosis.

Sterilization by the Aid of Alcohol.-Nye and Mallory in a recent issue of The Boston Medical and Surgical Journal show the fallacy of using alcohol for the sterilization of instruments, having proved experimentally that immersion in 70 per cent. alcohol for an hour fails to sterilize instruments infected with bacilli of the B. arogenes capsulatus group. Two postoperative deaths from gas bacillus infection led to a bacteriologic examination of the scalpels, etc., used after they had been subjected to the routine washing and sterilizing in 70 per cent. alcohol, and also to experimental control tests

with an anaerobic bouillon culture obtained from the knife blades, all of which showed abundant growth and gas after twenty-four hours' incubation at 37.5° C. Since the routine practice has been adopted of sterilizing all scalpels, scissors, and Bard-Parker knife blades with the other instruments in boiling water for twenty minutes no further cases of wound infection due to imperfect sterilization have occurred.

Infants Immune from Measles.-Ratnoff (Archives of Pediatrics, October, 1923) states that:

1. Infants under two months of age, whose mothers have had measles, are absolutely immune to infection with measles.

2. Infants under five months of age are relatively immune, and a certain number retain this relative immunity up to nine months of age.

3. After the ninth month they are as susceptible as older children, and practically all contract the disease on exposure.

4. Artificially as well as breast-fed infants enjoy this immunity, with a slight difference in favor of breast-fed infants.

5. The immune substances are probably chiefly conveyed to the fetus thru the placental circulation.

6. There is no substantial evidence that any important part of the immunity is due to the ingestion of breast milk.

Antitoxin in Diphtheria.-According to Platou, writing in the Archives of Pediatrics (September, 1923), the following conclusions are well warranted: 1. A new method of administering antitoxin, namely, the intraperito neal, is suggested for selected cases of diphtheria. 2. For infants and young children, the simplicity of technic in methods other than the intravenous is emphasized. 3. Local discomfort, an annoying factor in the subcutaneous and intramuscular methods, is absent in the intraperitoneal and intravenous methods. 4. General reactions are noted as a possible hazard, greater in the intravenous than in the other methods. 5. Absorption by the intraperitoneal route does not, of course, approach the intravenous where antitoxin is delivered directly into the blood stream. Early absorption of antitoxin, however, as shown by tests on the blood after intraperitoneal injection, is approximately five times greater after intramuscular injection. Within an hour it is more than sufficient to neutralize the circulating toxin in the blood in any case of diphtheria. 6. Absorption by the intraperitoneal method is more rapid in infants than in older children. It is among the former that the procedure finds its greatest use. 7. Intraperitoneal administration of antitoxin is a safe and simple procedure. It is particularly applicable in advanced cases where suitable veins for intravenous administration are lacking, and in moderately advanced cases in which intravenous injection is not considered neces

sary or advisable, but where more rapid absorption is desired than can be obtained by the intramuscular method.

Treatment of Hiccough.-Friedenwald and Levy (Med. Jour. and Record, February 6, 1924) state that at times, depending upon the severity of the condition, the simplest measures will overcome an attack of hiccoughs, while in other instances, none of our known remedies will exert the slightest influence. These simple remedies consist of sipping water, taking deep inspirations at regular intervals, or in exciting sneezing as by means of snuff, or tickling the nares or the throat, causing vomiting; or in forcible traction on the tongue; or by a sudden shock, produced unawares to the patient; sipping bits of crushed ice; pressure on the back of the neck; hypodermic injection of adrenalin chloride, 1 in 1,000; inhalation of amyl nitrite or ammonia; the ice bag or a mustard plaster to the epigastrium; lavage of the stomach; galvanism over the cervical area, etc.

In the more aggravated forms it is important as far as possible to determine the cause of the affection-relief frequently being afforded by overcoming this factor. If this is occasioned by dietetic indiscretions the stomach should be emptied by means of emetics, or better by lavage. Careful dietetic regulations should be insisted on and the various gastrointestinal disturbances as far as they bear a causative relation to this condition, should be relieved by means of appropriate treatment.

In many instances benefit is derived from lavage of the stomach with an alkaline solution; in other instances purgatives of various forms give relief. The following remedies have at times been found of value: Tincture of capsicum. Hoffman's anodyne, tincture of valerian, bromides and chloral, tincture of musk and oil of amber, cocaine, anesthesin, chloretone, belladonna or atropine and validol.

Of special value according to our experience is the remedy recommended in recent years by Macht known as benzyl benzoate. Inasmuch as this drug exerts its chief effect peripherally on the smooth muscle structures, it is most useful in the treatment of hiccoughs of probable peripheral origin. It should be administered in doses of from forty to sixty drops, well diluted, at two or three hour intervals. In renal disease, the usual associated uremia must be especially treated by means of hot packs and baths; pilocarpine or jaborandi.

In serious and persistent singultus, especially those forms complicating acute peritonitis, pancreatitis and following abdominal operations, opiates in the form of morphine or pantopon administered hypodermically and inhalations of chloroform are to be recommended early as a means of affording at least a certain degree of temporary relief.

In certain aggravated cases under our care, direct galvanization to the neck was the only means of obtaining relief. Recently D'Alessandro described a method which he has employed with much success. The left carotid sheath is

grasped by the thumb and forefinger, at the anterior border and midway between the origin and insertion of the sternocleidomastoid muscle. The sheath is compressed tightly for about one minute and the hiccough usually ceases immediately.

The author draws the following conclusions: 1. Hiccough is a symptom varying in intensity from a slight form to an extremely grave type, which may terminate in death.

2. It is important in the proper treatment of this affection to determine its cause as far as possible, which, however, may be extremely difficult in many instances.

3. Numerous remedies are recommended in the treatment of this affection, but are so uncertain that it is frequently necessary to take advantage of the various forms, one after the other, in the hope of obtaining a cure.

The Time at Which to Take Drugs.-Lemoine states that a medical man is sometimes taken aback when asked by his patient at what time he is to take his dose of medicine (Jour. de Therapeutique, France, October, 1923). The reply is sometimes given haphazard, but there are very simple rules which should be known. A drug acts more quickly when it is absorbed quickly, and it is absorbed the better when the stomach is empty. All prescriptions in which quickness of action is desired should come under this rule and the drug should be taken before meals. An hypnotic will promote sleep much more quickly if taken before supper than if it is swallowed before going to bed. It will act equally well in a small dose, for instead of being aborted en masse it will be slowly ingested from the midst of a bolus of food. The same thing applies to cardiac drugs, of which the dose is precise and it is wished to estimate the effect.

On the other hand, drugs the action of which is shown slowly and only take effect by a slow impregnation of the organism should be given at the end of a meal, which in most cases will allow a stomach full of food to tolerate them better than when empty. The iodides and bromide of potash, creosote, urotropin and others should be given in this way-in fact, all therapeutic agents the action of which is "long dated." The same thing applies to drugs with a disagreeable flavor. Lemoine always gives cod liver oil at the end of a meal, in the first place not to spoil the appetite, and in the next to avoid to a certain extent the unpleasant eructations. He gives it especially at the end of supper so that these latter are only produced during the night.

Some drugs must be given at a time determined by relation to meals. Bitters at least half an hour to an hour before the meal in order to have time to act upon the gastric secretions. With this object Leven recommends hot infusions before meals and not at the end. Others should be given at definite times to avoid upsetting the digestions, such as the alkalines, and particularly the bicarbonate of soda. Nearly always this is given at the moment of the meal,