THERAPEUTICS OF GOUT.

In an address before the Harvey Society of New York last April and published in the American Journal of the Medical Sciences for November, 1910, entitled "Uric Acid in Gout," the author, A. Magnus-Levy, discussed the therapeutics of gout. Touching on the behavior of the two drugs which had been found most efficacious in the paroxysm, colchicum and salicylic acid, he observed that salicylates in sufficient doses increased the output of uric acid materially, by seven grains and upward daily, but the action does not persist for more than a few days, when the effect disappears. Colchicum produced no change, or if it did, it diminished the quantity of uric acid elimination. The effect of colchicum was stated to be more rapid and more intense than that of sodium salicylate. How it acted the author did not state, though he observed it might inhibit the process of solution and thus put an end to the inflammation and to the paroxysm. If this conception were right colchicum would be only a palliative for the attack, while the salicylates, in spite of their slower action, would be the preferable remedy. Of all remedies deemed useful in chronic gout, alkalies had for centuries been applied more than all others. One theory favoring their use was that they dissolved the concretions of urates within the body, a theory entirely refuted by modern research. The other theory had to do with the supposed quantity of the alkalies of facilitating the output of uric acid, but experiments had not borne this out. He cited Roberts, who asserted that in a long experience he had never seen any distinct improvement even after administering alkalies for many years. What remedy can be substituted for alkalies? asked the author, and he then spoke of Falkenstein's resort to hydrochloric acid. Falkenstein reported that he got rid of his pains by the use of hydrochloric acid without having changed his mode of living, his diet, or his habits, and that he had also obtained good results in many patients. Other physicians, Dr. MagnusLevy said, had been less successful. Experiments with radioemanations were cited in the paper. It was noted that physicians were inclined at present to ascribe the undoubted efficiency of mineral waters not to the content of salts, but to the emanations of radioactive substances. Gudzent had observed that radioemanation was able to destroy uric acid. Since the emanation left the body rapidly Lowenthal constructed a respiration chamber in which the amount of emanation was kept at a high level. Thus the quantity of radioemanations from men rose to 150000 units. Preliminary experiments were carried out

last winter by Lowenthal and Gudzent in the clinic of Professor His but the results had not yet been published in detail and it was therefore difficult to form a judgment. In healthy persons the output of uric acid was materially increased, but gouty patients behaved differently

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EAR DISEASE.

Albert Bards, in the New York Medical Journal, declares that nearly every ear disease is a secondary complaint, the result of a general infectious disease, especially measles and scarlet fever in children and grippe and pneumonia in adults. Measles comes first in frequency. The otitis of measles is not particularly dangerous to life, but it is extremely injurious to the hearing, on account of its frequent invasion of the labyrinth. Five per cent of deaf mutism is attributed to it. Most deaf mutes are not born deaf, but become so in early life. All babies are born dumb; they learn how to speak through hearing others speak and imitating them. When, therefore, an infant loses its hearing before the faculty of speech is mastered, it naturally becomes dumb as well as deaf.

The otitis of scarlet fever is frequently a dangerous one. Its chief characteristic is the stubbornness it displays in getting well. Twenty per cent of all discharging ears are traced to it and frequently both ears are affected.

The otitis due to grippe is perhaps the most troublesome form we have to contend with. Very often it develops suddenly, with severe deafness and sharp pain. Hearing tests with the tuning forks show diminished conduction, both by air and bone-an evidence of internal ear implication, and a circumstance that adds to the gravity of the complaint and frequently interferes with the return of the hearing. As years roll by, the grippe ear increases in frequency, probably because we are becoming more and more enervated by our artificial ways of living. As a rule, in the course of a general infection, the ear does not become diseased until the second week, when the fever is declining and the relaxed bloodvessels are pouring out their exudate, the vitality is then low and the resistance is poor.

Surf bathing is a common source of ear trouble in summer, both from the impact of the cold water upon the drumhead and from snuffing the water up through the nose. Of late many middle ear diseases are being produced by the indiscriminate use of the nasal douche. Perhaps none of the physicians who prescribe the douche are aware of the harm it can do when the nasal passages are obstructed-precisely the condition the douche is given for. When the nose is block

ed the douching fluid is apt to be drawn up into the ear with a deep inspiration, carrying with it infectious matter from the nasopharynx. This is the cause of the frequent earaches among many douche users. These repeated earaches, like those that accompany severe colds, produce structural changes which often lead to progressive catarrhal deafness.

Recurring attacks of earache in a child suggest an obstructive disorder in the upper air passages, probably adenoids and large tonsils.

In all acute infectious diseases the mucosa of the middle ear undergoes the same inflammatory changes that the mucosa of the nose and throat does. Ordinarily the inflammatory exudate from the middle ear escapes by way of the Eustachian tube. When, however, the mucosa of the tube is unduly swollen, the fluid is dammed up behind it, and, accumulating, soon fills the tympanic chamber and the mastoid cells. It is the pressure of the imprisoned fluid upon the sensitive drumhead that constitutes earache. In infants the drumhead is so thin that it soon yields to pressure and ruptures. This is a fortunate provision for the roof of the tympanic cavity of a babe which separates it from the brain, is but a thin shell of bone, often absent, and this is easily eroded by an infectious excretion. In adults and in children whose drumheads are scarred from previous ear troubles, the drumhead is firm and resisting and the earache lasts longer.

An earache should always be given serious attention. We must bear in mind that we are dealing with an infection near the brain which may assume alarming proportions at any moment. If the symptoms are slight and the patient is strong we can attempt to abort the infection by rest, hot applications, fluid diet, a laxative, and possibly a single dose of morphine to ensure comfort-more than one dose masks the symptoms. Frequent irrigations with a warm bichloride solution, 1 in 5,000, are usually helpful and soothing. The familiar practice of putting an onion, an oil, or even a tincture, into the ear should be discouraged as being unseientific, uncleanly, and often harmful. Even leeching and putting carbolic acid and glycerin into the ear are of doubtful value.

Under no condition should the suffering be allowed to last longer than twenty-four hours without surgical intervention.

SURGICAL TREATMENT OF GRAVE'S
DISEASE.

The New York Medical Journal thinks that the indications regarding surgical intervention in

exophthalmic goitre may be summed up as follows: 1. Abstention in all the mild types which are susceptible of being cured by medical treatment. 2. In the cases of medium intensity, after a short trial with medical treatment without improvement, thyreoidectomy should be resorted to. The cases of medium intensity are really the true field of action as far as surgery is concerned. 3. The serious types are also in the domain of surgery, but the operation should be undertaken only after a careful and appropriate preparatory treatment. The technique to be followed should be that of Kocher or the Mayos. The contraindications are infrequent, but interference should not be undertaken where the patient presents marked cachexia. The same may be said of renal and hepatic lesions and especially those of the heart, such as myocarditis.

Although Kocher and the majority of the German school resort almost exclusively to local anææsthesia, it is perfectly safe, at least in cases of medium intensity, to employ general narcosis, preferably with ether. For the majority of surgeons, the procedure to be employed should be a unilateral thyreoidectomy, removing the lobe presenting the greatest degree of hypertrophy, that is to say, generally the right lobe. The operation may be completed by ligation of the superior thyreoid artery on the opposite side. This gives, according to Berg's statistics, eighty per cent of cures, instead of the thirty-seven per cent observed when simple thyreoidectomy without ligation is done. At the beginning of the milder forms of the disease ligation of the two thyreoid arteries alone may be done, as recommended by Mayo, and this is certainly without danger and frequently sufficient to control the development of the process.

The operative mortality has strikingly diminished in recent years, and at the present time, according to some twenty sets of statistics from different sources, death occurs in not more than five per cent. The statistics of some operators show that their mortality has been only from two to three per cent. Alamarthine, at the French Congress of Surgery, held in October of this year, gives the following summary of twenty-five sets of statistics: There were 669 cures or marked improvements, 174 slight improvements or none at all, and 63 deaths from operation; in other words, 669 favorable results and 237 bad. Consequently, it may be said that at the present time operative procedures give seventy per cent of successful outcomes. Such results are very encouraging, although quite in contradiction of the present opinion of many internists, who still consider an operation as a

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Second: "606" will probably be very pensive, while the cost of the other is merely nominal.

Third: "606" causes pain on injection, while the cacodylates do not.

Fourth: Of the two the instability of the dioxydiamidoarsenobenzol is the more marked, for while the cacodylates break down in a few months, giving off poisonous products, it is necessary to ship the other in hermetically sealed vacuum capsules to prevent immediate decomposition.

Fifth: The maximum dose of the cacodylates, for safety, 0.3 gramme per kilogramme, is twice the size of that of "606," 0.15 gramme per kilogramme (34), proving that in the experimental animal it is much more safe.

Sixth: The arsenic content of "606" is 34 per cent, while that of sodium cacodylate is 46.8 per cent; the latter, therefore, is capable of delivering, weight for weight, 38 per cent more arsenic. Theoretically there seems to be some grounds for belief that sodium cacodylate should be more than a third more efficacious.

Seventh: The entire dose of sodium cacodylate is dissolved in the blood, whereas a large percentage of "606" (40) remains unabsorbed and therefore unacted upon at the site of injection. Which means that those who have been treated with 606" afterward carry around in their persons indeterminate amounts of arsenic. This has in no way had any therapeutic action and is worse than wasted.

It should be said in favor of Ehrlich's compound, however, that that portion of it which enters the blood possibly breaks down with more ease and therefore delivers its arsenic content more readily than does sodium cacodylate.

In the opinion of the author the cacodylates have proved themselves worthy of a fair trial. For the only way of determining their practical value and their worth as compared with dioxdiamidoarsenobenzol is by the therapeutic application. Those who have the facilities for

the Wassermann reaction and spirochætæ determination have here open before them a field for work. However, neither drug has had as yet sufficient trial to prove that it is the ultimate specific, but such results have been reported from both that we have great hope that the problem of the diseases of animal parasitic origin has

been solved.

But the author, while advising the use of the cacodylates for this class of diseases, must emphasize the necessity for purity and the danger of deterioration. Use no sample that you have not tested, and if kept for any length of time retest the purity. Keep in glass stoppered or rubber corked bottles and make up all solutions fresh on the day of use.

REDUCTION OF ARTERIAL PRESSURE.

Rudolph, in the British Medical Journal, considers the spasm to be in the great majority of cases of toxic origin, and that attention should be directed to the lessening of this toxaemia, which is generally recognized to be due to nitrogenous bodies. In the intestinal tract certain bodies, technically known as the aromatic series, are produced by the decomposition of proteid materials; and these being absorbed may, either by direct action on the vessels or in some less direct way, produce vasoconstriction. These poisons must first pass through the liver, and, if this organ be active, may be destroyed there and do no harm. It seems to be especially the proteid of meat and eggs that produces most toxins. If the toxins once reach the blood they are chiefly got rid of by the kidneys. Hence it is that Huchard puts as the second most important factor in the production of the presclerotic stage. of arteriosclerosis insufficiency of hepatic and renal functions.

If the patient shows a family tendency to arterial disease the author advises putting him chiefly on a lactovegetarian diet, cutting out excessive smoking and the use of alcohol, and the administration of a saline every morning, with an occasional mercurial purge. If such a regime be not sufficient, regular small doses of potassium iodide may help very much. Diuretics may be useful, especially theo-bromine.

With regard to the use of vasodilators Dr. Rudolph says they usually act even in profound cases of arteriosclerosis and it has been shown that their action is more prolonged here than in normal vessels. He classifies them in the following order as regards their speed of action and associated evanescence of effect: Amyl nitrite, nitroglycerin, spirit of nitrous ether, sodium ni

trite, erythrol nitrate, and mannitol nitrate. The effect of the last named has been found to be more prolonged than any of the others.

He sounds a warning note regarding the quality of the spirit of nitrous ether as dispensed in Canada. There is, he says, no standard for strength in the British or Canadian pharmacopoeias, but in the American it must contain 4 per cent of the ethyl nitrite when freshly prepared. When made according to the directions of the British Pharmacopoeia it should contain from 2.75 to 1.75 per cent. Sodium nitrite also rapidly oxidizes and thus loses its action, so should be freshly prepared. Physicians probably often fail to get the action looked for with these drugs on account of these depreciations.

TREATMENT OF HYPERTENSION. Wm. H. Sheldon, in the Medical Record, says he thinks it plain that in cases where high tension has been long continued we have an unalterable pathological condition. Therefore, we must concentrate our efforts on prophylaxis. As long as physicians neglect to include in routine examination the taking of blood pressure we shall see these advanced cases. An apparently insignificant rise of 20 m.m. to 40 m.m. is worthy of attention, and it is the duty of the physician to ascertain the cause of this increased pressure, and to remove it, thus preventing the inevitable bad results. In a number of cases the cause of heightened pressure is simply an irrational mode of life, and when this is corrected the pressure falls to normal again. Careful attention to the many etiological causes of high blood pressure will suggest its cure in the early stages. Too often the high tension is treated with vasodilators, as if it were in itself a disease, whereas observation should have been directed to the cause and its removal. One cannot lay too much insistence on the fact that high tension is only a signal with its red light to warn the physician of a danger that lies in the pathway and menaces the life of his patient.

When the high pressure has been long continued and a pathological condition established, efforts must be directed toward maintaining compensation. In one respect at least we are dealing with a condition similar to that which exists in valvular lesions, namely, a leakage. If, as often happens, the arterioles are incapable of dilatation we must consider the effect alone on the heart. The question arises: Is or is not the heart compensating? If it is, we must do all we can to keep it so, urging an easy life with much rest and moderate exercise, a sensible diet,

baths, and massage. If the heart is not compensating the high tension seems no contraindication to digitalis. Indeed the author has seen the alternating pulse disappear under the use of that drug, which is contrary to Dr. MacKenzie's experience. Chloral sometimes has a magical effect in restoring the circulation without very often greatly affecting blood pressure. He is at a loss to explain its effect unless a greater amount of sleep and a sense of equanimity are responsible. Potassium iodide after prolonged use in some cases reduces systolic pressure and lowers the pulse pressure. Its effect, therefore, must be attributed to the actual changes it brings about in the arterial wall. The ordinary vasodilators have not met with favor as the author has been unable to reduce the blood pressure with them and has produced disordered stomach and headache. Moreover if the arteries are so degenerated that they will not maintain normal pulse pressure, it seems illogical to try to dilate the arteries, as by so doing we would too greatly lower diastolic blood pressure and the heart responding to the reflex would have to pump the harder to maintain a balance. With regard to the headache and dizziness supposed to be due to high pressure, the author has again and again seen them disappear with laxatives and diet, with no change in blood pressure. Most of the cases given above had excessive indican in the urine and he is inclined to believe that the headache and dizziness are due more to intestinal putrefaction than to high pressure.

Lastly the author urges the use of instruments in taking systolic and diastolic blood pressure. The usual method of taking it, by watching the movement of a mercury column, is misleading and, therefore, worse than useless. The graphic instruments of Gibson and Erlanger are admirable, but are too bulky and expensive for ordinary clinical work. An instrument has been devised by Mr. Nathaniel Fedde, a student of Cornell University Medical College, which seems to meet all clinical needs. The author has tested it, comparing its reading with those of the Erlanger instrument, and found it remarkably accurate. By this sphygmomanometer advantage is taken of the air compression produced by each pulse beat. The alternating increase and decrease which have so little effect on the mercury column cause oscillation of a pithball, the movements of which are of sufficient amplitude to be easily discernible and the last point of maximum excursion can be determined without difficulty.

CHRONIC CATARRH OF THE STOMACH.

S. Hewey, M. D., Camp Point, Ill.-The physiognomy of one who has long suffered from chronic catarrh of the stomach is like that of one who has recently lost his best friend and a portion of his fortune besides. His tale of woe is long and sad, enough to give one the blues. No use in telling him to "keep a stiff upper lip." His tongue is furred, the edges and tip often red. He has a bad taste in his mouth; his appetite is poor most of the time, though some have too good an appetite. The bowels are generally constipated, but there are cases where there is diarrhoea in which the food passes undigested. Vomiting is of frequent occurrence, the stomach in some cases rejecting the food just as swallowed. At other times it is sour or bitter. Eructations of gas after eating is at times persistent and very annoying. Pain in the region of the stomach after meals sometimes mild and at others very severe, is of frequent occurrence. Headache is a common symptom of chronic dyspepsia.

Sedentary habits tend to induce chronic indigestion. Overeating, and who does not overeat, is one of the most frequent causes of chronic catarrh of the stomach. Poor cooking and improper food derange the digestive apparatus. The use of tobacco is very often the cause of dyspepsia among men. Coffee, tea and alcoholic stimulants are among the causes of this common disease. In rural districts we do not often meet with chronic catarrh of the stomach as a result of the use of alcohol, though occasionally we do meet with an obstinate case thus induced.

Diet. It is impossible to lay down a course of diet that is adapted to every case and in all stages of the disease. Some things can and ought to be prohibited. Everything that produces pain, eructations of gas or makes the patient uncomfortable should be proscribed. Fat meat and everything that has been fried, especially fried potatoes. If the patient is in the

habit of using tobacco, he should abandon its use at once and forever. There is no such thing as tapering off with this narcotic; it generally tapers the wrong way. If one will persist in using it, he must and will pay the penalty. The use of coffee, tea and alcoholic liquor, if used daily, should be abandoned. Acid vegetables, as a rule, do not agree with a dyspeptic.

Lavage.-Lavage of the stomach every morning, or every other, with ten per cent solution of bicarbonate of soda, through a double, flexible stomach tube washes out some of the mucus and prepares the stomach for the morning meal, which may consist of buttermilk, or if sweet milk is preferred and agrees with the stomach. Sometimes it is necessary to confine the patient to milk of some kind for days. By and by a soft boiled or poached egg may be borne well. Then light bread, toasted until crisp, with a little butter, may be tried. In old very chronic cases we may have to advance and retreat as experience proves necessary. Of course, there are many cases that do not need so restricted a diet, but hot biscuit and fresh baked light bread should be counted out in all cases of chronic catarrh of the stomach.

Rest. In chronic dyspepsia the stomach needs all the nervous energy that it can get to digest the food, therefore the patient should rest body and mind for an hour after a meal.

Constipation. In chronic indigestion the bowels are generally constipated. For this a biscuit composed of two parts of wheat-bran and one part of flour, eaten instead of bread, generally remedies this trouble and likewise agrees with the stomach. When a drug is absolutely necessary, a granule of podophyllin at bed time or a small dose of sulphate of magnesia in the morning serves a good purpose.

Digestants. To aid the digestive process I have found sulphate of strychnine, sulphate of quinine and alcohol more efficient than any other combination that I have tried. One-thirtieth of a