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In chronic cases of bronchitis or advanced colds he sometimes uses senega, more frequently terebene and creosote. The ammonium salts, sanguinaria, squills, etc., he rarely uses. Stimulants he seldom finds any use for, although digitalis is given as indicated, especially if there are heart lesions. Morphine is used for the cough of any patient when it is excessively frequent.

In children his favorite remedy is wine of ipecac. For infants he advises mustard baths.

Dr. E. Junger, Soldier, Ia., also prefers ipecac as a nauseating expectorant, giving either the syrup or wine to effect in small or large doses according to the urgency of the symptoms. Apomorphine he does not employ.

To break up a cold he sometimes uses tincture of belladonna, gelsemium, lobelia, sanguinaria or syrup of Dover's powder, also tincture of aconite when indicated. The "laxative cold tablet' manufactured by Gering, of Omaha, is also a favorite mode of medication in these cases. In the early stage of acute bronchitis, syrup of Dover's powder with laxole is the indicated medication. Other remedies which may be employed during this stage are compound syrup of squills and compound elixir of heroin. When expectoration is tenacious and scanty, he combines the syrup of wine of ipecac with ammonium chloride. When the expectoration is abundant but weak, he gives lobelia, sanguinaria and nux vomica. Stimulants such as alcohol, digitalis, strychnine are used in asthenic patients, for those of weak hearts and lack of tone. Opium and its preparations are never used alone in diseases of this class. He finds the oil of eucalyptus a good sedative in chronic bronchitis.

His favorite expectorant combinations in treating the colds of children are syrup or wine of ipecac, tincture if lobelia, Brown mixture, Dover's powder. He uses these when the cough is excessive but non-productive.

Dr. B. G R. Williams, Paris, Ill., says that in routine work he gives ipecac orally, but emetine, its alkaloid, is prescribed when rapid action is desired. When very rapid and powerful action is wished for them he gives apomorphine hydrochloride hypodermically. The last named drug is a useful nauseant in the treatment of croup.

To break up a cold, his favorite remedy is Dover's powder. The National Formulary and official preparations which he finds of value as expectorants are: mistura ammonii chloridi (N. F.), Dover's powder, and the aromatic spirit of ammonia. Opium is employed early in the case only and along with stimulating expecto

rants.

Dr. Beverley Robinson, New York, N. Y., says that his favorite nauseating expectorant is ipecac, but it often causes intolerance of the stomach. Apomorphine he never uses as an expec

torant.

His favorite remedy to break up a cold and in his opinion the very best of all is syrup ammonii hypophosphitis (Gardner), 1 dram of this given every two or three hours to adults and children given proportional doses. He uses this also in the treatment of acute bronchitis. The old stimulating expectorants he rarely has use for. His best stimulant is good old brandy and as a heart tonic strophanthus is prescribed as required.

When opium is indicated he gets good results from small repeated doses of deodorized tincture of opium in camphor water.

Dr. Ernest F. Robinson, Auburndale, Mass., says that when nauseating expectorants are needed, he uually gives emetoid alone or in combination. Sometimes apomorphine is prescribed. usually in granule form in small doses, frequently repeated.

To break up a beginning cold, he advises Calcidin alone or in combination, which he considers one of his most valuable remedies. Dover's powder is also a good remedy. Another good expectorant is the old Stokes mixture, which is sometimes very valuable. All of the stimulating expectorants are prescribed from time to time as indicated. However, alcohol he never use, strychnine often and digitalis occasionally when there is special indication. phine and codeine are prescribed when indicated, but he does not use narcotics if he can possibly help it.

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His favorite expectorant combinations in children are Calcidin and Dover's powder modified (Abbott Alkaloidal Company). Dr. Robinson states, however, that in his present practice he does not deal largely with acute cases of this character.

Dr. S. J. Wright, Akron, O. As an illustration of his method of practice he cites the case of Mrs. C. who had pertussis at the age of thirteen and has coughed all her life until lately. She was thin but has two children able to attend school. High frequency current was applied to her throat and nose to sterilize them. The Roentgen rays were used to disintegrade toxins and cause reaction against bacterial invasions. Oxygen inhalations were prescribed for their local and general effect. Her nasal hypertrophy was treated with glass (vacuum) electrodes. Her strength, color and flesh returned and her cough ceased.

THE MONTH IN BRIEF.

HINTS FROM THE THINKERS AND DOERS IN MEDICINE.

The Medical Treatment of Cholelithiasis.— Anderson has a thoughtful paper on this subject in the Monthly Cyclopedia and Medical Bulletin. He arrives at the following conclusions:

1. While surgical intervention is frequently the best, and often the only means offering a chance of relief, its advocacy, based on certainty of cure and assurance of non-recurrence, is not borne out by results.

2. The main object of treatment is the relief of the infection and inflammatory changes, and not merely the removal of the gall-stones. So long as there is no recurrence of the inflammatory attacks, there will be no attacks of gall-stones. 3. Recovery not infrequently occurs under nonoperative treatment, especially in early and mild cases, and particularly after first attacks, before serious local damage has been produced by the infection.

4. Medical treatment should be given a fair trial in all cases where the patient's physical condition does not warrant operation, and with the numerous patients who refuse operation. In many such cases complete and permanent recovery from all symptoms of the disease will result.

5. Medical treatment is indicated in many cases as a preliminary to operation, and in order to allow the acute infection to subside as far as possible.

6. Medical treatment is indicated in all cases after operation, to allow of complete subsidence of the infection and, if possible, to prevent reinfection and recurrence.

7. It would make for clearness of thinking and give definiteness to therapeutic aims if we adopt the suggestion of Naunyn to give up the term cholelithiasis and classify these various infections of the biliary passages as cholangitis, with qualifying terms such as simple, catarrhal, suppurative, gangrenous, calculous, etc., according to the condition present in the particular case.

The therapy suggested by Anderson includes the copious use of Carlsbad or other alkaline waters in hot water; rectal injections of hot water; plain diet, food at frequent intervals; salicylates and

bile-salts for their cholagogue action and hexamthylenamine, to sterilize gall-passages; vaccines, though he has no personal experience; and prolonged rest in bed. It may be added that sodium succinate has been warmly recommended in these cases, and is deserving of trial.

VE VE VE

"Stealing the Thyroid," and Anoci-association-Removal of the thyroid gland is an operation attended with a high mortality.

The dread of the operation, the sight of the operating room, the ether anesthesia, and the noci impulses to higher centers from trauma to the neck tissues have all contributed to the high shock mortality in these operations. To avoid these (see paper by Colcord, Int. Jour. Surg.), Dr. Crile proceeds as follows:

1. Obtains consent of the patient to operate. Gives the patient a few days or weeks of rest in bed.

2.

3. Applies a stock collar to the neck similar to that which will be worn to hold dressings in place after operation.

4. Gives daily "treatment" of oxygen from an apparatus similar in appearance to that from which later the nitrous oxide will be administered. 5. When ready to operate anesthetizes the patient in her bed (she thinks she is only going to get an oxygen treatment), and takes her to the operating room.

6. Completely blocks all nerves in tissues to be divided with infiltration local anesthesia of 1:400 novocain, thereby cutting off all afferent impulses to the brain.

7. Avoids all rough handling of tissues, all pulling, crushing, tearing, etc.

8. Catches and ties all important bloodvessels before cutting, making the operation almost bloodless.

9. Infiltrates the tissues with solution of quinine and urea hydrochloride before suturing.

10. Applies the stock dressing and takes her to her bed while still anesthetized.

The effects of the novocain are short, but those of the quinine and urea hydrochloride last for

two or three days. Hence the patient experiences no discomfort and does not know she has been operated until the first dressing. There has been no shock upon her, no changing pulse, no fright and consequently no "hyperthyroidism." By this method, not only has the mortality been greatly lowered, the unpleasant things connected with the operation have been minimized, but the long period of extreme nervousness so often seen after these operations has been avoided.

In abdominal operations in Crile's clinic, the patient is given 1/6 gr. of morphia and 1/150 gr. of scopolamin one hour before operation. The operation is done either under local anesthesia alone or that combined with nitrous-oxide-oxygenether anesthesia.

If a general anesthetic is used, the tissues are infiltrated with 1/400 novocain layer by layer before cutting, great care being taken to turn up the parietal peritoneum and anesthetize it. As in the thyroid operation the tissues are handled with the greatest gentleness.

How Much Antitoxin?-This question, which every physician must ask himself when called to treat a case of diphtheria, was admirably answered by Dr. Thomas Darlington in 1912, when Health Commissioner of New York. He said:

"All patients over one year old who have been ill from twenty-four to thirty-six hours, and show membranes limited to the tonsils, should receive at least 5,000 units. Patients over one year with membranes extending to the soft palate and uvula, or to the posterior wall of the pharynx, should receive 10,000 units as an initial dose, while in similar cases with the additional involvement of the nose or nasopharynx the initial dose should be at least from 12,000 to 15,000 units. In septic cases where the patient has been ill for from five to seven days, with necrotic membrane of foul odor, a tendency to hemorrhage from the nose or pharynx, and petechial spots upon the skin, enormous doses may be administered-up to 20,000 units. Even larger doses have been given. All croup cases should receive at least 10,000 units, and if the pharynx is involved with the larynx, 15,000 units. It is frequently necessary to repeat the dose, and the indications for this are: (1) If, after twenty hours, the false membrane is spreading, or does not show signs of curling at the edges; (2) If the general condition is not improved, as shown by the state of the pulse and the lessening of mental apathy. The latter is an extremely valuable guide, for in cases where sufficient antitoxin has been given its improvement is more rapid than that of any other symptom. In croup cases the dese should be repeated unless the

obstruction has become less marked. In all cases the second dose should be as large as the first. The indications for the third and fourth doses are the same as for the second, but the interval between the third and fourth doses may be reduced to twelve hours. When a maximum of from 40,000 to 50,000 units has been reached it is useless to administer more antitoxin. Further injections only increase the suffering of the patient."

To this may be added the advice of Dr. William H. Park, who tells us that best results are obtained by giving the antitoxin in a single dose instead of in a divided dose. He directs the use of 5,000 units in mild cases, 10,000 in the more severe, and 20,000 in the most severe. In the last, the antitoxin should be given intravenously, if possible.

The Use of Radium in Malignant Diseases.— Robert Abbe, of New York (Lancet, August 23, 1913), draws his conclusions from observations made upon 750 individual cases. Many forms of tumors which are not malignant respond to the use of radium in a most satisfactory and prompt manner. Epithelioma of the skin can be cured permanently with radium, and perhaps better than by any other known agent, and with the least scar. The worst types of cancer of the breast or uterus in women, and of the stomach, esophagus, tongue and rectum usually show prompt and marked amelioration under large doses of radium, but temporary gains are lost. Giant cell bone sarcoma can be controlled promptly and certainly by radium. In no case of pure myeloid sarcoma has radium failed to cause retrogression and arrest of the condition. It may be concluded: (1) That there is an undoubted retrograde degeneration of malignant cells under the correct dose of the gamma rays from radium. (2) That the effective use of the drug lies in the application of a large enough amount to avoid the stimulant action of small doses at close range. (3) The alpha and short beta rays may be removed by filtration through lead. (4) Under such filtration a much longer time is required for the gamma rays to act than when the other rays are eliminated by what may be termed "distance filtration." In practice, one and one-half inches seems to exclude most of these, permitting free and instant play of the gamma rays without the delay of passage through lead. (5) Cross firing is necessary for

the best results.

A Study of Defectives.-In the state of Indiana, says H. M. Carey in the Illinois Medical Journal for November, a study made in connection

with 511 families, in which there were known to be mental defectives, yielded the following figures: Total number of persons in 511 families, 1,924 Supported in public institutions, 1,334. Feeble-minded, 1,249. Insane, 54.

Otherwise defective, 44.
Illegitimate, 267.

One or both parents defective, 1,024.

In the state of Pennsylvania, at this time, there are from 15,000 to 18,000 defective individuals who are not receiving care and attention. Some few years ago they constituted but a small percentage of the population. Today this has increased, partially due to the fact that we are better able to recognize the condition, but more particularly due to the fact that no restriction has been placed upon them, and that they have been allowed to multiply both within and without the bonds of matrimony.

Kindly bear in mind, says Dr. Carey, that this conditon is a defect, not a disease. It is largely hereditary; it is incurable; it is increasing. It is costing the community more each year, and this cost continues to increase directly in proportion to the number of individuals. Also bear in mind the fact that once defective, always defective. Environmental conditions may be changed, the individual can be properly cared for; he is happier and better, but he is not cured. That the condition is hereditary goes without question.

XXX

Inheritance of Hysteria; Violent Temper and Eroticism.-Dr. Charles B. Davenport, of the Carnegie Institution, after investigating some inmates of a girls' home for the determination of the influence of heredity came to some very interesting conclusions relative to the presence of symptoms usually called hysteric. He says that violent temper, threats of suicide, love of fabrication, impulses to steal and to set fire to buildings, profane and obscene speech, and great indolence are all associated with violent erotic tendencies. And all of these traits showed themselves to have a marked hereditary basis.

In considering the significance of this complex of symptoms, it soon appeared that we have here to do with many of the principal elements of hysteria, without the striking motor symptoms frequently found in that condition.

On account of the frequent association of violent temper and eroticism with feeble-mindedness in the families of these hysterical girls, Davenport entertained the hypothesis that these characteristic traits would all prove to be like typical feeblemindedness, recessive in the Medelian sense, i. e., be inherited as a biological defect. Upon

analysis, kleptomania did, indeed, prove to behave as though dependent upon a biological defect. such that when, in the makeup of both parents, the determiner that makes for honesty is lacking it will be lacking in all the children, while if either parent is honest at least half of the children will be so also. But the two traits of violent temper and eroticism are inherited in a different fashion; namely as a Mendelian dominant. There is never a generation in the direct line that is skipped. Though one side of the house be without a tendency to such behavior while the other side have the tendency at least half of the children will have the tendency.

The behavior in heredity of violent temper and eroticism is therefore in striking contrast with the behavior of feeble-mindedness and we may designate the hysterical condition as one of feeble-inhibition in contrast to that of feeble-mind.

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A Test for Hepatic Function.-The November number of the Johns Hopkins Hospital Bulletin contains two papers on a new test for hepatic function, contributed by Rowntree, Whipple and others. These gentlemen have discovered that a phenolphthalein derivative, one which remarkably like that useful chemical in physical and chemical properties, to-wit, phenoltetrachlorphthalein, when introduced into the blood by the intravenous route, is excreted solely by way of the liver and the intestine, just as another analogous substance, phenolsulphonephthalein, is excreted exclusively by the kidney and bladder. It was suggested that this fact might be utilized in the determination of hepatic function, so an elaborate series of tests was made, both on man and the lower animals, to determine its value.

The technique was, roughly, as follows: With care, and according to a method described, a 5 per cent solution of phenoltetrachlorphthalein is prepared, and of this 8 Cc., containing approximately 400 mg. of the chemical is introduced intravenously, with all aseptic precautions, with 50 to 100 Cc. of water or salt solution, 10 to 15 minutes being consumed in doing this. Before giving the drug, active purgation is instituted, with compound cathartic pills, and this is continued during the time of collection. The stools are collected for 48 hours and the urine for 24. Now, in a normal person, not suffering from disturbance of hepatic function from 30 to 45 per cent of the phenoltetrachlorphthalein will be recovered in the feces. This method of recovery is described in detail. When the percentage falls below that specified the presumption is, in the light of the present evidence, that the liver is not functioning properly. The animal tests bore out that assump

tion, which was also supported by the clinical

tests.

The writers report a series of 80 tests on 67 patients. There were normal controls and various types of liver cases. Some of the interesting facts elicited are, that pyrexia has no effect, per se, on the excretion.. Only in severe grades of secondary anemia was hepatic function impaired. In myocardial disease, hepatic function was impaired in half, but evidently this impairment only results when the heart insufficiency is extreme. In one case of cirrhosis of the liver the excretion was only 6 per cent; in others it was greater, yet below normal. Three cases of carcinoma of the liver showed 6, 7 and 14 per cent excretion, respectively. In one case of amebic abscess there was 23 per cent excretion, a week after drainage had been provided for. These statements give an idea as to the scope of the test.

The greatest disadvantage of the test is the trouble of collecting and testing the feces. There may be some local pain, but this apparently is never great or troublesome. The fate of the unrecovered portion of the test drug is unknown.

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Eye Diseases Connected with Dental Affections. Terson has reported to the Académie de Médecine (Paris Médicale) cases of spasm of the eyelids, of neuralgias, divers abscesses, of obstinate lacrimation, glaucoma, intraocular hemorrhages, orbital and even cerebral abscesses, all of which were related to dental diseases or operations performed on the teeth. The superior first molars are more frequently the cause on account of their vicinity to the antrum of Highmore. The other teeth, even those of the inferior maxilla, may also have a share in those troubles.'

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mann (Muench. Med. Woch., 1913, p. 1022) tried, with excellent success, continuous intravenous infusion, using digalen and adrenaline in saline solution. By means of adhesive plaster, the cannula was permanently fastened to the arm, the drop rate being controlled by the insertion of a Martin glass bulb. Thrombus never was encountered.

The advantages claimed are, that the fluid may be instilled continuously for hours without risking complications from overburdening the heart. Blood pressure does not rise unduly rapidly, as in the customary massive infusions, at once, but rather is maintained evenly during the period of procedure.

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Formic Acid and Urea Excretion.-According to Pic, who quotes the studies of Garrigue, Huchard, Martinet, Michelozzi, and others (see Paris Médical, Nov. 1, 1913, p. 498), formic acid increases metabolism within the body, as shown by an increase in the elimination of urea, which, in the cases of Garrigue, increased from 20 Grams to 52 Grams in twenty-four hours. Even when this medication is prolonged, it produces no harmful reaction, provided the remedy is taken during rest. Until we are better informed concerning the action of formic acid and the formins upon nutrition, however, Pic warns that we should be very careful in their employment.

Paracodeine is a new synthetic preparation lying between codeine and morphine in action. It is said to be more sedative than codeine. It is soluble in warm water.

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