Administering Quinine in Malaria.-The Germans have studied the treatment of malaria with great care, both in Germany itself and in the German colonies in Africa, where the more severe forms are very prevalent. The general consensus of opinion favors Nocht's method. This consists in the administration of 0.2 grm. (3 grains) of quinine hydrochloride five times daily, making a daily dose of one gram- or about 15 grains. This treatment is kept up for eight days. The after-treatment with smaller doses extends over two or three months. The results are said to be quite as good as with the more usual larger doses and the method has several advantages. such as the avoidance of cinchonism and of hematuria and the greater promptness with which the administration of quinine can be inaugurated.

Methylene-blue and arsenic have also an antimalarial action, but in this respect are not to be compared to quinine. The only other drug equal in efficiency to quinine is salvarsan in tertian malaria.

The Freud Theory.-Schwab, in the Interstate Medical Journal, thinks the value of the Freudism philosophy to the neurologist depends largely on the personal experience of the one who hapAs a therapens to be trying the method out. peutic measure it has without doubt won for itself a place which cannot be denied. The effect upon the patient is less easy to determine. How far the educational effect will extend, and how nearly it will restore the victim of a neurosis to a normal being, are things that cannot be answered at the present time. By what standards are we to measure the curativeness of a method as intricate as this, and further by what standards are we to measure a patient in respect to his state of being cured. Neither Freud nor his students have concerned themselves with questions of this kind nor, perhaps, do they see the necessity of attempting to do so.

There remains then this fact, and it is a stubborn fact. Almost everyone who has used the Freudian methods, after careful preparation, has

continued its further use, and the larger his experience grows, the more evidence he finds of the correctness of the Freudian assertions in general and the less incongruous and strange do the majority of them appear. This has been about the experience of the author to whom Freud's work has up to within a fairly recent time been of vital theoretical interest, but singularly impracticable as a therapeutic application.

Perhaps what is of value in the Freudian psychology is that indefinite part of it, which happens to be true, and this part is a large or small proportion of the whole depending upon the insight of him who happens to be the analyst. At any rate it seems fair toward such a vexatious question to take a kind of pragmatic attitude. Let us assume that such part of the Freudian scheme is true which happens to be of use, and proceed further in the assurance that its utility tends to increase with its further application.

The Thymus.-Klose, in Archiv. fur Kinderkraken, states that percussion is not very valuable in the diagnosis of thymus enlargement on account of its uncertainty, while radiography must not infrequently be desisted from on account of the excitement which this procedure often produces in the infant. The diagnosis of thymic enlargement is based on chronic symptoms of compression of the deeper organs of the neck, the occurrence of paroxysmal exacerbations, and the protrusion of a tumor in the jugular fossa during expiration. The presence of these symptoms demands early operative interference, so that a fatal. issue during one of the exacerbations of the stenosis due to thymic congestion or even hemorrhage may be averted. Intubation and even tracheotomy are of no permanent benefit. preferable operation is intracapsular dislocation and ectopexia. The procedure is readily performed and in most cases leads to permanent cure. In case of failure enucleation of the left lobe or excision should be performed. The author collected 23 operative cases from the literature. A cure resulted in 19 cases, improvement in 1. In

The

been so impressed by its main truths that he has the 3 fatal cases the operation was performed too late.

Sydenham's Chorea.-Bradford, in the American Journal of Orthopedic Surgery, gives the following summary of the pathology, symptoms and treatment of chorea:

(1) Sydenham's chorea is a manifestation of rheumatic infection.

(2) It is an organic disease of the brain, attacking all parts of the cortex equally and impartially, but affecting the basal grey matter less severely.

(3) Consequently the symptoms are not only motor, but also psychical and sometimes sensory.

(4) The motor symptoms are partly due to loss of inhibition, partly to cortical irritation.

(5) In chorea the fallacy of the distinction between "functional" and organic nervous disease is exemplified.

(6) Chorea can be fatal without the occurrence of meningeal inflammation.

(7) This fact, with the phenomena of latent chorea, suggests that chorea may be due to direct intoxication rather than gross infection of the cranial contents.

(8) The tendency of chorea is toward restoration of health to the brain.

(9) Treatment consists of (a) removal of the cause, active rheumatic infection, by rest in bed with administration of salicylates during the active stages; (b) prolonged mental and bodily rest during convalescence; (c) improvement of general health by fresh air, full diet, and tonics; (d) quieting of excessive movement by sedative drugs or packs, and cure of paresis by massage. (10) The full-dose arsenical treatment is useless.

(11) Chloretone is only useful in certain cases, and should not be given as a routine

Humidity in Climate.-Goldsbury, in the Boston Medical and Surgical Journal, concludes that the problem of constructing buildings in such a way as to keep the interior up to a fair degree of humidity is a large one. So far engineers have made little practical progress toward its solution. Their ingenuity has been taxed to improve the moisture in large public buildings. The devices for this have so far proved too expensive for private dwellings, hotels, offices or schoolhouses. Another difficulty has been to arouse public opinion on the subject, or to convince of its importance. Americans complain of the drafty, poorly heated buildings abroad, but

American houses are both too nearly air-tight and too much heated for ideal humidity. Too little of the moist fresh air enters; and this, under the rising temperature, has its relative humidity greatly lowered. The situation calls for some special measures.

It is well simply to call attention to the fact that clothing and covering of the body interferes more or less with an equal shading of humidity and evaporation and circulation of the air directly over the skin. Advantage may be taken of this fact. If the skin is allowed to enjoy longer periods of freedom from clothing upon retiring or rising, or when they are being changed, the body will be bathed more equally by air of a like degree of humidity and should benefit from such baths. Clothing which permits freer circulation of air is a step in this direction, but this whole subject can be reserved to a later discussion.

If one must live much indoors he may improve the temper of his rooms by various devices, such as keeping growing plants and setting about porous dishes, as flower pots, full of water. If such receptacles are set near electric fans the stirring of the air facilitates evaporation. Some housekeepers have even placed such pots within the radiator.

The Pelvis and the Sigmoid.-Channing W. Barrett, in Surgery, Gynecology and Obstetrics, presents the following conclusions:

1. The intimate relation of the genital tract to the terminal reservoirs of the urinary and alimentary tracts permit of easy communication of disturbances, and pathologic conditions.

2. The sigmoid through its ready adhesions may, like the omentum, serve to wall in a genital infection and save the patient, after which it may through perforation serve as a means of escape for this infection and the resulting pus, or by reason of adhesions, it may introduce new elements of danger through colon bacilli infection and bowel obstruction.

3. The symptoms of constipation, diarrhea, passage of mucus or blood, the presence of sausage like mass in the left iliac fossa, etc., should lead us more frequently to include the pathologic conditions of the sigmoid in our pelvic diagnosis, especially when there seems to be adhesions on the left side.

4. The associated sigmoidal conditions are undoubtedly primary, in many instances, as they are found in men although adhesions here may be due to infections of the vas but are also very frequently secondary to the disease of the tubes, ovaries and uterus, as they are frequently observed after definite infections of this tract.

5. An intra-abdominal investigation of pelvic disease should include inspection and palpation of the sigmoid when with few exceptions leftsided and not infrequently right-sided pelvic trouble will be found accompanied by adhesions, obstruction, and kinking of the bowel or making undue traction upon the bowel or the tube or ovary or both.

The Alcohol "Stimulant" Fallacy.-Crothers, before the American Therapeutic Society, declared the apparent stimulation of alcohol was simply irritation, and not increased power or capacity. One very large and carefully conducted experiment was made with typesetters in a government office in Germany, where the results of small doses of alcohol, given at intervals, were increased errors, lessened work, greater fatigue and measurable anesthetic action. A great variety of similar experiments, with the same results, had also been made in this country. It was a curious fact that a large part of the literature regarding the value of alcohol as a stimulant and tonic is based on tradition, superficial views and unsupported personal opinion. The teachings of, prominent authors had been accepted without. question. Thus, Todd, Bennett and other clinicians who extolled the stimulant properties of alcohol made an army of converts, who unhesitatingly accepted their conclusions, and even today physicians of the older school insisted that these early teachings were correct. One of the first breaks in this delusional evidence was furnished by mortality statistics showing a higher death-rate under the use of alcohol as a stimulant. Dr. Crothers spoke of its employment in pneumonia, diphtheria, tuberculosis and other affections, and said that many papers in this country had called attention to the fact that alcohol is a very dangerous drug in collapse states, partieularly following typhoid fever. Here, while there would be an apparent resuscitation for a short time, the depression which followed resulted in more profound collapse.

Renal Tuberculosis.-Barth, in Deutsche Med. Wochenschrift, makes the following statements:

1. Certain kidney excreting tubercle bacilli, and those having encapsulated tuberculous foci, may possibly heal spontaneously. However, this may never be expected in those cases showing definite pyuria with abscess formation already present in the kidney. This is true because observation teaches that in such cases the process will become disseminated both by the lymph stream and by the contaminated urine to the

remainder of the urinary canal. The healing of such cases in which he admits the possibility, may only be determined by repeated ureteral catheterization. All other signs are deceptive and worthless.

2. Nephrectomy done for unilateral renal tuberculosis, after determining normal function in the opposite kidney, is an operation practically devoid of danger.

3. As long as the disease is confined to one side; nephrectomy offers an excellent prognosis for permanent cure from tuberculosis, as far as concerns the urinary system. However, if the bladder is already affected a permanent cure may be expected in only one-quarter of the cases. About the same number die in the first year of tuberculosis, and the remainder have a very much better prognosis as to duration of life and condition of health.

4. A distressing sequela of bladder tuberculosis, even after complete healing, is polikiuria, especially at night.

5. Every case of renal tuberculosis should come to nephrectomy, if possible, before the bladder is involved.

6. So-called "open" tuberculosis of the kidney can in its incipiency and early stage only be diagnosticated by ureteral catheterization, which procedure, as well as a complete bacteriologic examination, should be made in all cases of obscure pyuria or "bladder catarrh.'

Pyelitis During Pregnancy.-Colman, in Deutsche Med. Wochenschrift, states that there are various dangerous renal conditions complicating pregnancy which demand energetic surgical interference, e.g., pyonephrosis causing a large tumor, multiple abscess formation, etc. However, in those cases in which the pathology is confined to the mucous surfaces, radical surgical procedures are as often out of place as the mathematical interruption of pregnancy.

Ureteral catheterization clears up in many cases doubtful diagnosis and permits a differentiation between cholecystitis and appendicitis, and the lesions of the urinary tract. In those cases in which high temperature, thick purulent urine, and stormy symptoms are absent, catheterization of the ureters is often the first thing to put one on the right track. Through its use the too common diagnosis of cystitis of pregnancy may be corrected, and disease higher up in the tract be discerned. He calls attention to a case of a pregnant woman who had long been treated for cystitis and only after catheterization of the ureters was a diagnosis of pyelitis made. Pyelitis does

not occur only in the latter months of pregnancy, and Colman recites a case with very severe symptoms in the third month, who after internal treatment made a complete cure. He states from his experience that pyelitis is not confined to one side and that the right, as is usually asserted. He found half of his cases were bilateral. On irrigation of the renal pelvis all cases were markedly helped. The relief is as rapid as is noted on the incision and evacuation of an abscess. Pain, fever, and general symptoms, as well as the danger of interruption of pregnancy, are all allayed.

A complete cure, however, is not effected by irrigation, as the pyelitis of pregnancy is closely analogous to kidney of pregnancy and a true recovery does not take place until delivery. Colman recommends the washing out of the renal pelvis in those cases in which the usual internal treatment has proven insufficient.

Nature's Vaccine Therapy.-Clive Riviere, in the Proceedings of the Royal Society, points out that autoinoculation is the escape into healthy tissues of the toxic product of bacteria developed during the course of the disease. Autoinoculation may be assisted by hyperemia, as: heat, in fomentations; massage, as in friction; Bier's hyperemic treatment; stimulating lotions locally applied; medication that acts directly upon the part involved. As soon as the invaders land there is a call for more blood, more plasma acts, destroying them both by chemical process (oxidation, hydration, and dehydration), and by the action of the specific antibodies. The leucocytes rush out to ingest the foe. If this is insufficient, antibodies are formed in response to the toxins carried through the body in the blood stream and the resistance of the plasma is thereby increased. Nature was the earliest vaccine therapeutist.

In assisting Nature by induced hyperemia, we have several natural processes to study and imitate. First, irrigation of the infected area by plasma and leucocytes, and this of itself may be enough to cure a mild affection. Second, autoinoculation, or washing of the bacterial products into the blood stream to stimulate in the tissues the formation of antibodies to the invading microorganisms. We are all vaccine therapeutists, as annoying as it may be for us to realize it. It is this natural vaccine therapy that was exploited with succcess by the time-honored custom of applying hot fomentations, etc., to the inflamed area. By this means not only was irrigation assisted but such irrigation, of itself of value, necessarily helped to an increase of that autoinocu

lation on which the improved resistance of the body depends. Such an effect is obvious, as far as the hyperemia is concerned. In the application of hyperemia, the influence of the physician has been solely in the direction of irresponsible irrigation, but nature's armamentarium contains in addition the weapon autoinoculation, a weapon to be brought into use where irrigation alone has failed. The physician has neglected this weapon; he has been an irrigator pure and simple. To be sure, autoinoculation has necessarily occurred as the result of this irrigation, but has he directed it? Has he applied his fomentations at such intervals that time may be allowed between for the formation of antibodies? Has he calculated at what intervals he should autoinoculate his cases to maintain most successfully their toxic immunity? As a matter of fact, he has done none of these things.

Mineral Acids in Gout.-The Medical Record reminds us that a generation ago an English practitioner, who was an unattached individualist, created quite a sensation by publishing numerous cases from the ranks of his aristocratic patrons in which reports he always gave the antecedent treatment as prescribed by other notables (whose names he invariably repeated and whose prescriptions he regularly reproduced). His method was often simplicity itself. After a client had consulted some world-famous authority (who stood sponsor for a special therapeutic principle), and had become decidedly worse as a result, our individualist simply reversed the principle of the treatment, and-if we choose to believe himpromptly cured the patient. Apparently he went no further into the rationale of the treatment. Thus if a peer had chanced to consult Sir William Gull for his gouty paroxysms and had become distinctly worse after large doses of alkalies, the individualist merely changed the treatment to full doses of nitric acid, whereupon the patient at once experienced decided relief.

Quite recently Schmidt of Frankfort has advocated the use of hydrochloric acid in persistent high doses for certain cases of gout. But unlike the English empiricist he has a definite reason for this procedure, which, moreover, has its special indications. The treatment did not originate with him, for long ago the discovery was made that gouty patients often suffer habitually from defect of acid in the stomach. The biochemical studies which throw light on this mechanism are too numerous and complicated to be cited in this connection. They naturally involve the entire biochemical pathology of gout and of uricemia; and

eventually of all the chronic affections which are found associated with gout.

Encephalitis Following Salvarsan.-Fisher, in Muenchner Med. Wochenschrift, comments on the surprising tolerance of the organism to intravenous injections of salvarsan, but insists that there must be individual examples of intolerance which must always be borne in mind. It may be recalled that some of the worst recorded cases of iodism were traced apparently to organic disease of the kidneys which was responsible for a highly toxic cumulative effect of the drug in subjects already suffering from syphilis. Something of this sort must be anticipated whenever the emunetories or disintoxicating organs are are insufficient for the added demands made upon them. This element divides with anaphylaxis the responsibility for therapeutic tragedies. The patient in question was himself a medical man accidentally infected with syphilis, for which he had been duly mercurialized and had also received iodides. Salvarsan was then infused and although the Wassermann reaction had now become negative the patient became very ill at night after his usual daily routine. The symptoms suggested severe intracranial mischief and death occurred in coma in a little over twenty-four hours from the onset of the attack. The case is summed up as follows: It is known that between two and three days after an infusion of salvarsan an acute edema of the encephalon may develop, but that this quickly resolves itself and only exceptionally does a fatal encephalitis develop. Since this phenomenon has been noted chiefly after repeated injections there may be an anaphylactic element concerned (the patient had had a previous injection). Precisely the same accident has been known to follow mercurial injections in syphilities, and it is believed that the action of syphilitic toxins on the encephalon is a contributory cause in such cases. When the patient first suffered from his general explosion of syphilis the cerebral symptoms were prominent. Finally the autopsy disclosed a beginning cirrhosis of the liver. The lessons from the case are in part obvious.

Advantages of Modern Lithotrity.-Luys, in La Clinique, describes the advantages which the modern operation of lithotrity has over hypogastrie section. One objection urged against the former has been that it is an operation in the dark. This objection may be disposed of by the statement that cystoscopy permits adequate inspection of the work accomplished by the lithotrite. In the hands of the skillful this operation is not a difficult one.

The steps in the operation are as follows: 1. Dilatation of the urethra if this is narrow or stenosed. 2. Preparation of the bladder; if this has a capacity less than 150 grams, it should be treated previously by means of lavage and instillations of nitrate of silver. 3. The urine should be examined for glucose and albumin and particularly for its content in urea. 4. By means of the cystoscope it is necessary to determine the nature, size, and location of the calculus. 5. On the eve of the operation a sound should be passed into the urethra, and the patient should be given a purge. The operation comprises three steps: a, the crushing of the stone with the lithotrite; b, the evacuation of the fragments with a syringe or an aspirator; and e, the examination of the interior of the bladder with the cystoscope, to determine whether all the fragments have been removed. The contraindications of lithotrity are as follows: If the calculus is too large, exceeding 7 cm. in length, one may experience great difficulty in crushing it. If the stone is too hard even for a large lithotrite, one should not persist in the crushing operation, but should proceed to hypogastric section.

Marriage of Girls with Heart Disease.-Jashka discusses this problematic subject in Muenchner Med. Woch. He is concerned chiefly with the effects of pregnancy on the mother. In regard childbearing by women with vulvular lesions he cites many figures to show that the danger is exaggerated. Women with such lesions continue to bear children. The type of a case described by obstetricians as contraindicating pregnancy and as furnishing a special obstacle to delivery is an extreme one and leads us to another type of case, to-wit, that with impairment of the myocardium; with actual chronic insufficiency. The diagnosis of the intimate nature of this lesion is difficult at best. Many varieties are found under this head, for chronic insufficiency of the heart is not necessarily due to degeneration of the myocardium. Fatty infilteration, guiter-heart, congenital stenosis of the arteries, pressure lesions, etc., may cripple the normal action of the heart and must be separated from actual disease of the myocardium, which latter, when in evidence is sufficient to contraindicate marriage and pregnancy. In regard to pure neuroses of the heart, these not only do not contraindicate marriage, but may at times be improved by it.

Treatment of Chronic Disease.-J. Madison Taylor, before the American Therapeutic Society, declared that to secure the best results in pro