Bulletin. Apart from fresh air Dr. Cohen places his dependence upon the following measures:

First, the effective use of massive doses of quinine. The most potent preparation, namely the very soluble double hyprochloride of quinine and urea, has been chosen, and one of the most active methods of administration, namely, intramuscular injection of a 50 per cent solution, is employed.

Second, the hypodermic injection of cocaine hydrochloride solution or of an extract of the posterior lobe of the pituitary body for the maintenance of blood-pressure.

Third, in cases of prolonged fever, delayed resolution, or tardy convalescence, the injection of bacterins (pneumococcus or "mixed" vaccines, personal or stock) has been resorted to, in an endeavor to expedite recovery, and apparently with good result. Further experience with this is needed before positive general statements can be made. But in special instances the good influence has been striking.

The details of the treatment are thus summarized by Dr. Cohen:

On admission, so soon as the diagnosis is verified, the patient, if a fairly strong adult, receives under proper precautions an intramuscular injection of from 1 Gm. (15 grains) to 1.6 Gm. (25 grains) of the quinine and urea salt in 50 per cent solution in hot sterile water. Children, the aged, and the feeble receive smaller doses. The injection is repeated, but rarely with a greater dose than 1 Gm. (15 grains), every third hour until the temperature falls, and remains, below 102.2° F. One-half grain (0.03 Gm.) of cocaine hydrochloride or of caffeine (sodiosalicylate) or 1 c.c. of pituitary liquid (representing 0.2 Gm. of fresh posterior lobe) or 1 c.c. of a 1:1000 solution of the posterior pituitary principle is injected hypodermically at the same time with the first dose of quinine, and repeated, likewise, every third hour, until the curve representing systolic blood-pressure in millimeters of mercury (taken in the arm), rises and remains above the curve representing pulse frequency in beats per minute.

This latter practice is founded on the observation of G. A. Gibson, of Edinburgh, concerning the prognostic significance of the relation between pulse frequency and blood-pressure, thus charted. I have proposed to call this relation the Gibson pulse-pressure ratio, and trust that the suggestion will be adopted, as a worthy means of perpetuating the memory of that great clinician, whose recent demise is so marked a loss to medicine.

The injections of quinine are governed in part by the temperature and in part by the general

symptoms. The injections of cocaine, caffeine, or pituitary preparation are governed chiefly by the pulse-pressure ratio, but also by the general character of the pulse and of the cardiac action, the renal activity, and the general symptoms. Sometimes these agents are alternated; sometimes camphor (2 to 10 grains in sterilized olive oil) is used as an adjuvant or temporary succedaneum. I have also used epinephrin, atropine, strychnine, and even digitalis preparations and principles on occasion. But the routine is usually cocaine and the pituitary preparation.

Creosote carbonate is sometimes administered by mouth during or after the course of quinine, if called for by special symptoms; less frequently (in cases in which extremely viscid sputum is expectorated with difficulty) ammonium salts (usually bromide, acetate, or carbonate) or terebinthinates are given, or inhalations of appropriate vapors instituted. In other words, special symptoms are relieved when necessary. But this is not an invariable part of the routine.

No invariable maximum limit has been fixed to the number of the injections of quinine, of cocaine or of pituitary liquid, but it has not been considered wise to continue the three-hourly injections beyond the first twenty-four hours, and in but few cases has it been necessary to continue them so long as this. In those cases in which the desired effect, as indicated by temperature or by the Gibson blood-pressure pulse rate relation, has not been reached within the first twenty-four hours, the interval between the injections has been increased to six hours. When the effect is gained, the repetition of the doses depends on the maintenance of it.

In general, the effort is made to give as much quinine as is necessary and can safely be borne within the first forty-eight hours, and as little cocaine or pituitary or camphor, etc., throughout the treatment, as is necessary to maintain the systolic blood-pressure curve at a safe distance above the pulse-rate curve. Proper attention is given to the excretions and to the quality as well as quantity of the urine. Suline infusion, alkaline-saline beverages to the point of keeping the urine alkaline, external applications of heat by flaxseed poultice, electric heating pad, or cotton or lamb's wool jacket, and in rare instances oxygen inhalation are among the auxiliary methods employed routinely or in selected cases. But it is unnecessary to dilate on these, or on the details of diet and nursing, which are to be taken for granted.

The change in the character of the defervescence from crisis to lysis, together with the great symptomatic relief afforded by the quinine

in the presence of an unchanged evolution of the pathologic process in the lungs, justifies the belief that the effect of the drug is antitoxic; and this conclusion is further strengthened by the entire absence of cinchonism, notwithstanding the enormous quantity of quinine administered and absorbed. I can speak only from careful clinical observation. There appears to be a mutual neutralization of quinine and pneumonia poisons. This in a measure tends to prevent cardiovascular (or sympathetic) paralysis, which is the most dangerous element of the morbid process. In cases seen early a very few injections suffice, in some cases only one. In cases seen on the third day, or later, more active treatment is needed; and, moreover, aid is needed to support cardiovascular (sympathetic) tone. This assistance is furnished by cocaine, by pituitary, by epinephrin, and in less degree by camphor, by atropine, by strychnine, and even, when the quinine is used, by digitalis.

Concerning the great superiority of treatment by quinine and pressure-raising medicaments over all other routine or expectant methods yet proposed, I have not the slightest doubt. It has in my own hands cut the mortaltiy of the severest cases in half. But this is not its only merit. The comfort, especially the relative ease of respiration of the patients, even of those who do not recover, is wonderful to see. The entire clinical picture is changed.

When bacterial therapy and serum therapy are sufficiently developed to be applied with precision in supplement to quinine, I confidently expect the mortality of pneumonia to become so small under the combined method that I hesitate to suggest a probable figure, lest I be deemed extravagant in my optimism.

A word as to the duration of treatment and the number of injections. The quinine injections are rarely continued beyond seventy-two hours, and the number of injections in this period (each, in most instances, containing 1 Gm.) ranges from 1 to 15. In one exceptional case of double lobar pneumonia, 22 injections were given, with good result. The number of cocaine or pituitary injections throughout the course of treatment ranges from 1 to 20. In an ordinary case-if there be such a thing-the number of quinine injections will be about 5 or 6, and the number of cocaine and pituitary injections 3 or 4 each. But in this, as in all other features of the treatment, there must be individualization. tine is a guide, not a fetich. And the dose of any and every agent is that which I have elsewhere laid down as a general principle-enough (to produce the effect desired) and no more.

The rou

TREATMENT OF VARICOSE ULCERS. Here is the method of treatment for varicose ulcers advocated by Arthur L. Parks, in the Medical World:

The part should first be cleansed once or twice daily. Take warm soapsuds and wash carefully and thoroughly. Use fomentations of boric acid, acetate of lead or acetate of aluminum. When the skin is not tolerant to moisture, dust with iodoform (substitutes of this drug fall short, in my estimation), boric acid or naphthalin. Orthoform may also be used, but care must be exercised, since it is known to cause gangrene. The "Scott-Schley" method covers the ulcer thickly with boric acid (pulverized), over which are placed several layers of rubber tissue held in place upon the sound skin around the borders of the sore by adhesive plaster. Over this is bandaged a protective pad of gauze. This dressing is not removed for several days (possibly five days to a week).

Thus far in our treatment we have said noth

ing pertaining to the effecting of an improved blood supply. To this end keep the patient in the recumbent position with the leg slightly elevated. Keep him in this position until the scar has become sufficiently resistant to assure his making the change to the upright with impunity. Of course, we know there are certain cases whose physical condition would not permit of this recumbency for days without dangerous results. When circumstances do not permit this treatment, bandaging may be employed. And remember it takes a lot of pains to bandage properly and efficiently. It should not be left for the nurse to do, but should be done by the physician himself.

The idea of bandaging is to bring about an even pressure which stimulates absorption of the exudate, thus loosening the adhesion and removing pressure from the vessels, therefore permitting an easier entrance and departure of the blood. Bandages of plain rubber, rubber cloth, elastic stockings, etc., may be used, but judgment must

be exercised in the use of the one selected.

In the application of the bandages one must be sure that the skin underneath them is kept perfectly clean and well powdered. For the comfort of the patient the treatment should be carried out in the morning rather than in the evening.

Unna's paste is another method of support. The leg is cleansed and the paste applied from foot to knee, followed by a gauze bandage, then another layer of paste, continuing in this manner until several thicknesses have been applied. The paste consists of

.1 part ..6 parts

Blistering is said to bring about a result similar to that produced by Unna's paste, and also induces an acute hyperemia. I have never resorted to blistering. Where the blood supply is interfered with by surrounding cicatricial tissue, it is advisable to loosen up the callosities by radiating incisions, to increase the circulation and to permit contraction of granulation surfaces. Now, do not make mere scratches for incisions, but go through the thickened margins down to the fascia.

Hyperemia may be secured ofttimes by free removal of the base of the ulcer together with the entire thickened margin. After such procedure disinfect with hydrogen peroxide or, better, chloride of zinc. Of late I use tincture of iodine, full strength.

Thoroughly scraping an indolent ulcer or rubbing off the granulations will sometimes produce a renewed activity. Cauterization with silver nitrate stick, pure phenol hydroxide, a 10% solution zinc chloride, or the electric cautery, repeated every few days, will likewise do this.

Meantime, while you are giving heroic local attention do not forget the systemic side. If all else is forgotten, remember, keep the intestinal tract free. The reasons are obvious when given a little thought relative to the mechanics of the circulatory apparatus. A well-balanced, nutritious, easily assimilated diet with a lot of fresh air. If the patient can afford to take a trip with pleasant friends and a good physician so much the better.

Operations for the removal of varicose vessels are frequently done. In considering the advisability of such treatment the general condition of the patient must be carefully taken into account. The operation may consist of multiple ligation, ligation of the internal saphenous alone, extirpation of large or small sections of the varices, or circumcision of the skin of the leg above the ulcer itself, tying all the veins and reuniting the cuticle.

Skin grafting is frequently resorted to with excellent results.

country as "crushes," in England as "raves" and in Italy as "flames." Their occurrence is almost universal among institutions for girls in the adolescent period, but there seems to be no exactly comparable phenomenon among boys of a similar age and in similar circumstances.

The relationship in question is of great importance, because it exerts in a large number of cases a vital influence over the girls concerned-in many instances the most weighty influence bearing at the time upon the developing character. This being the case and the truth of the preceding statement cannot be doubted-the subject should receive most careful attention at the hands of educators. Several questions demand determination. Is the manifestation beneficial or harmful? Το what extreme does it go and in what degree is it susceptible to suppression or control? If it is inevitable, how can the resulting influences best be

moulded and directed?

Yet this important phenomenon, well-known as it is, has received practically no scientific study. Every school-teacher dealing with girls must have made first-hand observations regarding it, but few of these have been recorded in the literature. I have spoken to several principals of schools where I knew "crushes" to be rampant, yet all of them disclaimed the existence of such infatuations in her institution and pleaded ignorance regarding the phenomenon. They had heard, however, that such things existed in other schools. All of them seemed to have a feeling of shame over the matter; whether this was due to the apparent silliness of the relation or to an instinctive apprehension of danger, it was impossible to determine.

To say the least, the matter seems to be of great pedagogic importance, and the object of the present mention is to urge some first-hand studies of the question by those dealing with schoolgirls addicted to crushes. It is not possible at this time to make an exhaustive review of the subject but for the benefit of those interested-and there should be many-a brief summary of the facts may be set forth.

The phenomenon of the crush has undoubtedly a sexual basis. It is synchronized accurately with the adolescent period, and the infatuation with another girl is often the first social manifestation of the dawning sexual impulse. Being directed towards another girl it is, of course, of a homosexual character. In the majority of instances, however, the relations are of a spiritual nature only, so this latter circumstance need not be too seriously regarded. It is well, however, that educators should know that in some cases these schoolgirl infatuations lead to physical relations. Such situations should naturally be guarded against.

Some details of these have already been mentioned in this journal. The salient feature of the relationship is its temporary character. It is of short duration only, being usually terminated by the entrance of some young man into the emotional life of one of the girls. This influence transcends the other and displaces it. We are thus led to conclude that the universality of the phenomenon is due to the need of an objective focus for the direction if not the gratification of the sexual impulse. Affectionate regard for another girl seems, therefore, largely faute de mieux.

In the present state of knowledge, the crushes do not seem to have a harmful effect upon the girls concerned, though any conclusion on this subject at the present time must be tentative only. It is clear, however, that the manifestation is fraught with several dangers which can be intelligently avoided only by an understanding of the considerations involved. An imitation of these dangers may be gleaned from the prevalence of inversion in various internats and convents. There devolves upon educators the duty of throwing more light on this important subject.

PITUITRIN IN OBSTETRICS.

Dr. E. Hirsch, of the Hebammenschule (school for Midwives) in Strasburg, writes of his experience with pituitrin in obstetrics as follows:

The uncertainty with which such old ecbolics as quinine, sugar and electric, thermic, and mechanical irritants are acting induced the search for new and better ones. We used pituitrin, whose eminent effects are being lauded by many, in 32 cases. This number in a total of about 400 deliveries which were here performed during the last five months is so small for the reason that we endeavored to be very critical about the indications for the use of pituitrin. We injected pituitrin in primary and in secondary insufficient labor-pains. In 3 cases it was done prophylactically before performing cesarean section; 13 times in premature [induced?] birth, 11 of which were done in connection with metreurynsis (dilation of the uterus by means of the metreurynter); 19 times in term-births. Of the whole. 8 were primiparous and 22 multiparous births.

In the first 10 cases the older preparation was used, in which 1 cubic centimeter of the fluid corresponds to 1/10 Gram of the fresh substance of the infundibular part of the pituitary gland. In the next 22 cases the newer preparation, of the same firm, was used, which then was put on the market, and of which 1 cubic centimeter of the fluid (contained in sterilized glass vials) represented 1/5 Gram of fresh glandular sub

stance. The injections of pituitrin were made intramuscularly exclusively, never by the mouth. Dr. Hirsch gives very instructive detailed descriptions of the course of the 32 deliveries where pituitrin was given, but "The Gleaner' has not space enough allotted him to render them here and he would commend them to grace some worthy obstetrical journal. He can only say that the remedy was administered both before and during delivery. In one case of a primipara the labor-pains continued for a long time, yet the os was not larger than a 5-mark coin (about the size of our silver dollar); but at the same time the fetal heart-tones were bad enough to indicate the need of a speedy termination of the delivery. Then pituitrin was given, whereupon the womb was emptied in the course of twenty minutes.

The experience reported from various quarters, to the effect that the efficiency of pituitrin is the greater the further advanced the parturition had progressed, and the greatest at the expulsion period, we ourselves can fully confirm. A short-handle forceps can be dispensed with in the cases where the parturient woman is under the influence of pituitrin if there is no immediate danger either for mother or child.

In one case in which by way of laparotomy we enucleated a myoma from a uterus in the third month of pregnancy without interrupting the pregnancy, we injected 1/10 Gram of pituitrin at term, on account of labor-pain weakness, with good results and without the least damage to the very attenuated walls of the body of the

uterus.

In four cases, where parturition was not really yet in progress, the injection of pituitrin resuited in but transient, and that very weak, pains lasting one hour. Repeated injections after that did not result in pains of a stronger quality. But here, too, we cannot speak of a total failure of action.

We have to distinguish between pituitrin refusing entirely to act, within a given time, when we should expect a stimulating influence upon the labor-pains; and between pains that are of such short duration or are so weak that they cannot be ascribed to any essential influence of the pituitrin. We meet with such cases in the first period of the dilation of the os uteri. Here neither stimulation of pains nor an increase of their strength could be noticed.

In a uterus that is still in a state of inactivity, even though at the end of the calculated term of pregnancy, we cannot, by pituitrin alone, start parturition with introductory labor-pains, even by repeated injections of it. But here, too,

after exciting pains by mechanical means, such as metreurynsis, tamponing of the cervix or introducing of laminaria tents, the pains once thus started can be increased by injecting pituitrin. Pituitrin is not a direct inciter of labor-pains; it incites them only when they had set in but then ceased; or it strengthens and re-enforces them when they are present, but insufficient.

The results of experiments to strengthen by means of pituitrin, labor-pains that were incited by the galvanic current will be reported upon later.

Harmful effects cannot be ascribed to pituitrin, according to our experience. As to its influence upon the fetal cardiac sounds, we can confirm Vogt's statement; for we noticed that these sounds still were slow at the end of a pause after a pain and had not yet recovered at the beginning of the next pain. Slight asphyxia of the children and two atonic hemorrhages of a slight degree that happened we could not with certainty ascribe to the use of pituitrin.

We found no inducement to use pituitrin in the placental period. We agree with Hofbauer that, in hemorrhages of the placental period, pituitrin can be dispensed with, for the reason that in conducting that period expectant we seldom see the occurrence of a severe atony. That the administration of pituitrin during parturition should influence the placental period so as to accelerate its detachment, as Fries has found, we have not observed in our cases. Moreover, the sekacornin La Boche served us so excellently, and it is so cheap, that we could reasonably dispense with pituitrin in the placental period. The results of our observations may be summed up as follows:

It is impossible to start an abortion or a premature artificial miscarriage with pituitrin alone, for it is not an inciter of labor-pains. But when the pains have once been started by means of metreurysis or cervical tamponades, they can be greatly strengthened by injections of pituitrin.

When parturition is already going on (the dilation period), then pituitrin is able in most cases at least to start up again pains that have ceased, or to strengthen them when they become weak, and to prolong them and to develop their greatest effect in the expulsion period.

The use of pituitrin recommends itself before performing a cesarean section, on account of its favorable effects on the contractility of the uterine musculature.

慌慌慌

PROVERBS RELATING TO DIET.

There is a maxim ascribed to Theognis, according to which "Surfeit has killed many more men

than famine," and Hippocrates had an aphorism that "Everything in excess is inimical to Nature." The former maxim finds modern equivalents in "Surfeit slays mae than the sword" (a Scottish proverb from Ray's collection), and a Latin counterpart in "Non plures gladio quam cecidere gula." Two other Latin proverbs put the same idea in different words: "Multo plures satietas quam fames perdidit viros" and "Multos morbos multa fercula fecerunt." A laconic adage says, "Much meat, many maladies;" an outspoken one says, "Quick to the feast, quick to the grave;" and a farseeing one announces that "Feastings are physicians' harvests." physicians' harvests." The Spanish rhyme "Mas mato la cena che curo Avicena" (The supper has killed more than Avicena cured) is a popular maxim.-British Medical Journal.

Truth That Comes From the Brothel.— Whether you agree or not with the following statement made editorially in the Medical Council you will find it worth thinking about:

"It is a rather hard commentary upon our civilization that the brothel has taught venereal prophylaxis to the laymen more effectively than has the medical profession. Even so, the methods of the brothel as to prophylaxis are worthy of . consideration. But it has taught one very dangerous procedure-the use of the bichloride vaginal douche. This should be wholly abandoned except, possibly, upon the operating table. As a wash for men, it is probable that more or less benefit has resulted. To be highly commended to their more circumscribed sisters is the general bodily cleanliness and the systematic vaginal toilette of the prostitute. They almost universally employ creolin or lysol or other cresol preparations, and non-specific discharges (which rapidly proliferate gonococci owing to the serum therein) are systematically cleansed from the vagina. In certain aspects, the prostitute is the cleanest woman in the world."

Dr. Bland may be right-but we doubt it. We must not lose sight of the fact that the prostitute is still the most dangerous source of venereal infection. The report of the Chicago Vice Commission proved that the majority of these women suffer from syphilis or gonorrhea, and the New York survey (see "Commercialized Prostitution in New York") gave the same testimony. From the standpoint of disease the prostitute certainly is not "clean".

Minute doses of phosphorus are recommended for the treatment of pneumonia. Calcium, guiacol, and the defervescent alkaloids also of merit in this disease.