however, that expert testimony under ordinary circumstances is worthy of the courts' highest consideration and justly entitled to a worthy place in the special field of medico-legal practice. The case in which Dr. Dixon was called upon to testify is an example, and the decision rendered does a great injustice to Dr. Dixon, who is a man of sterling worth, strong convictions regarding the rights of his profession, and above all an honorable and trusted physician. The Illinois State Medical Society championed the rights of Dr. Dixon, and his defeat will be honorably borne by this society, even if it means defeat to the cause of honorable expert testimony, and no pay for honorable service. The courts evidently think the laborer is not worthy of his hire and that medical men are simply puppets bound to dance when the string is pulled by the honorable court. Again is medicine compelled to bow in abject humbleness before the will of the mighty men of law who never witness a signature without adding, "So help me God, twenty-five cents.' They make sure of their fees by calling upon their Creator to aid them in its collection, while we poor followers of the healing art must grovel in the dust and await the pleasure of the courts vested in the power that makes even the dogs of war bark in derision and the statue of justice to blush at their powers of discrimination. F. P. N. THE confidence which physicians and patients alike have in a druggist is what gives reputation, trade and prosperity to his business. Without this Substitution. a druggist is lowered to the grade of the shyster lawyer, the quack doctor and the fake merchant man. Confidence, then, is the word that gives him capita!. He must ever maintain this reputation, and do all he can to protect the professional honor of the physicians who prescriptions are filled in his store. A prescription compounded with substituted drugs, reacts first upon the physician, then upon the druggist, while the patient primarily suffers. Two innocent individuals then suffer because of the perfidy of the druggist, while he himself loses what man holds dearest of all his possessions, his good word. Substitution, then, is an evil which in its enormity now is a giant of vast destructiveness, and he who would fight it must do so at the fountain-head. Insist upon what you write for, and under no consideration accept "any just as good," for it will give the druggist a lever with which he can move on future occasions your feeble resistant qualities. Firmness on the first offense will avoid future disturbances, and leave behind you an impression that you know whereof you speak, and propose to have your order executed to the letter. It is always well to patronize the druggist you can trust, and encourage your patients to remember the druggist who is found substituting. We hold that substitution is a criminal offense, and hope some day it may be so regarded by the courts. F. P. N. THE earnest student of medicine finds much food for thought in the vast strides being made in medical progress. As he goes about daily using the accumulated practical knowledge of ages, in the treatment of his patients, he sees in retrospect the heated conquests, the struggles, of truth with prejudice and error from which has arisen our present broad but comprehensive science of medicine. Prejudice and While the struggle yet is on with such insectivora as Still with his absolute quackery and bunco methods of practice, there is, however, a feeling among the educated men of medicine, as expressed by Osler, that modern medicine is "Free, cosmopolitan, no longer hampered by the dogmas of schools and we may feel a just pride in a profession almost totally emancipated from the bondage of error and prejudice." This harmony is destined to grow for already the signs of the times impress the sectarians in medicine with the fact that there is but one science of medicine as there is of astronomy and geology. Medicine cannot rest on dogma for it must move on and on this account we see pathy after pathy being relegated to oblivion, and the true light of medical science shining through the mist of ages of pathy and dogma. These progressive liberal views of medicine have been asserting themselves, one after another, until now we see the lines of demarcation between so called "homeopathy and allopathy" are being obliterated. doomed, it cannot live for regular medicine, which has never taken to itself the designation of allopathy which Hahnemann assigned it, has progressed so universally that the science of medicine to which pathy is attached is but the remnant of predjudice and error which still lingers to taunt true science. Homeopathy is doomed. Its principles of medication through evolution have lost their pathy and are coming into the ranks of the true science of medicine. This union is due to the progressive element of the younger members of the homeopathic profession and the liberal members of the regular profession, who are willing to drop prejudice and shake hands with a brother practitioner whose aim is their aim, whose interests are their interests and whose belief in medical culture is their belief. Now it is that the waging war of pathy is being quieted by the evolution of science, and ere long the physician who believes in culture and who looks beyond predjudice to the high ideal of a physician's life, will accept as a brother the thoroughly educated man in medicine. Such freak of medicine as osteopathy can never expect to come within the shadow, much less enter the portals of the halls of true medicine, for ignorance is their folly and wisdom is not written on their banners. True culture, honest endeavor and unadulterated principles are the tests of a qualified physician. The osteopaths cannot comply with a single requirement and hence should and will receive the condemnation of science and be ostracized from culture. While so-called homeopathy will lose its distinctive peculiarities and enter into fellowship with the workers in the broad and liberal science of medicine. F. P. N. Books, pamphlets, instruments, etc., for this department, should be sent to the Managing Editor, Saint Louis. A SMALL work, but a very useful one, especially valuable to the student. A description of the beginning, course, ending and uses of each bandage, is THE ROLLER BANDAGE, WITH A CHAPTER ON given. The illustrations, which are plentiful, are reproductions of photographs taken in just that stage of bandage application which has been found to be puzzling to the student. The chap ter on surgical dressing is short, concise and consistent with the principles of clean surgery. G. W. T. DR. PENROSE prefaces this work with the statement: "I have written this book for the medical student," and the work is, above all others we WOMEN.-By have seen, a book which will appeal to the student. Each year we see our medical schools approach nearer the rational method of instruction, that is, the textbook method, and such works will hasten the day when didactic lectures shall be, as a rule, the lot of post graduates only. This text book covers the subject. It gives all that is best of modern theory and practice. In many instances but one plan of treatment is given and confusion of methods so obviated. Anatomical, physiological and pathological facts which belong to text books on these subjects are omitted except where necessary to an understanding of the disease under consideration. As a whole the work is characterized by the clean, clear manner in which the subjects are handled. The publisher has gotten out a most attractive volume, one quite in keeping with the text. It is in every way suited to the use of all who desire a practical hand book on gynecology. A TEXT-BOOK OF DISEASES OF THIS is the thesis which won Dr. Mynter the Doctorate degree at the University of Copenhagen, twenty-six years after his graduation therefrom. APPENDICITIS AND ITS SURGICAL TREATMENT, After a thorough review of appendicitis, pathologically and clinically, the author concludes that it is a surgical lesion and the treatment is surgical. The differential diagnosis between appendicitis and conditions having similar symptoms and physical signs is clearly set forth; this point alone making it a valuable work on the shelves of the general practitioner, an early recognition and correct treatment being_indispensable to success. The technique of operation is given in detail. The seventy-five cases are well chosen and clearly stated, failures as well as successful terminations being recorded. G. W. T. PAPERS for the Original department should be in hand one month in advance, and contributed to THE MEDICAL FORTNIGHTLY exclusively. A liberal number of extra copies will be furnished authors, and reprints may be obtained at reasonable rates, if request accompanies the manuscript. Engravings from photographs furnished free. Contributions, books and exchanges should be sent to the Managing Editor, Union Trust Building, St. Louis. Signature of contributor, for reproduction, should be sent with every article, on a separate slip; use heavy ink, and allow autograph to dry without applying blotter. IT The Neuroses of Gout. BY L. HARRISON METTLER, A. M., M. D., CHICAGO, ILL. Presented at the Meeting of the Mississippi Valley Medical Association, held at Louisville, October 5 to 8, 1897. T would have been better, perhaps, if I had entitled my paper the gouty neuroses, instead of the neuroses of gout; for it is my purpose to speak of the nervous manifestations of the gouty or lithæmic state. Literature is full of diverse opinions in regard to the immediate cause of these nervous manifestations. There are three more or less prominent theories. The followers of Haig believe that the uneliminated uric acid in the blood affects somehow the blood vessels, so as to alter the circulation and nutrition of the nervous tissues. Others hold that these nervous symptoms are merely the expression of an inherited or acquired neurotic condition, of which the production of true gout and lithæmia in some individuals, is but another manifestation. The inherent nature of the troubles under consideration is entirely neurotic, and the faulty innervation is the cause of the arthritic deposits in true gout, and of the vicious metabolism in lithæmia. Still others argue that the gouty neuroses are not due to the uric acid in the blood, nor are they the mere expression of an inherited neurotic constitution. They are the result of an autointoxication springing out of the gouty diathesis, the uneliminated poisons being something else than uric acid, namely, the peptotoxins, leucomaines and ptomaines, sudol, volatile, fatty acids, ammonia, methane, sulphuretted hydrogen, acetone, etc. substances are being constantly formed in health in small amount, but in the gouty state they accumulate along with the uric acid, and being retained act as direct irritant poisons to the nervous structures. I have always been inclined to regard the last as the probable tneory, for several reasons, two of the more convincing of which are: the variable amount of uric acid found in cases of similar neuroses, as well as its decided diminution in many cases of actual gout, and the prompt and efficient relief obtained in many instances of typical lithæmia by vigorous purgation, diuresis and diaphoresis alone. Some recent studies in regard to the production of uric acid seem to point to the correctness of this view, In a discussion of the alloxuric bodies at the last meeting of the American Medical Association, Dr. Futcher, of the Johns Hopkins University, demonstrated that in gout and the gouty affections there is a diminution, as Kolisch teaches, in the uric acid, and an increase in the xanthin bases elimination. These alloxuric bodies, so designated by Kossel and Kruger, are made up of uric acid with various xanthin bases, and are derived from the disintegration of the nuclei throughout the organism. They represent the combined amount of uric acid and xanthin excreted. Horbaczewski first advanced the notion that the major part of the nuclein found in the organism results from the destruction of the leucocytes, and that leucocytosis is always accompanied by increased elimination of uric acid. In spite of some objections to these views, it is generally admitted that the elimination of uric acid is influenced by the number of leucocytes in the blood. In 1894 Neusser went so far as to declare that the peculiar granulation which he had observed about the nuclei of the leucocytes was due to the uric acid diathesis, and might, therefore, be used as a means of diagnosing that condition. He claimed to have found this granulation, not only in true gout, but also in what he termed "irregular gout," such as the manifestations of muscular rheumatism, nervous asthma, certain gastro-intestinal derangements and skin affections, leukæmia, neuralgia and neurasthenia. He believed that the increased elimination of uric acid and its relatively increased proportion to urea (the normal being I to 50) were directly due to the disintegration of the leucocytes, as shown by the peculiar perinuclear granulation. Kolisch, a pupil of Neusser, observed in gout and in the gouty state, an increase in the total alloxuric substances in the urine, but the increase was due to an increase of the xanthin bases, rather than of the uric acid. For the most part these observations have been confirmed by Weintraud and by Futcher. Kolisch's suggestion, that many of the symptoms of gout are to be attributed to the xanthins, rather than to the uric acid, has been very favorably received, and would seem to be somewhat supported by the marked increase in the excretion of paraxanthin in migraine and epilepsy, observed by Rachford. According to the later views of Garrod, Latham and Luff, uric acid is produced only in the kidneys and when found in the blood, as Garrod first taught, it is there by reabsorption from the kidneys. Futcher has shown in opposition to Neusser and Kolisch, that there is no proportionate rela tionship between the quantity of alloxuric bodies eliminated in the urin and the amount of perinuclear granulation observed in the leucocytes. all probability, therefore, the uric acid that is found in the blood in the form of the quadriurate is a reabsorption from the kidneys. If these observations are accurate in regard to the increased elimination of the alloxuric bodies in gouty conditions, the increase being due to an increase of the xanthins with an actual diminution of the uric acid--observations for the presentation of which I have drawn largely upon Dr. Futcher's paper in the Journal of the American Medical Association for July 31, 1897, we may have to reconsider the whole question of the influence of uric acid in the production of the symptoms of the uratic diathesis. The diminution. of the uric acid; its production in the kidneys; its reabsorption into the blood; its appearance there as a quadriurate and biurate at its final deposition in the joints, as the biurate of sodium, add special significance to the words of Sir William Roberts, uttered in his Croonian lectures before the Royal College of Physicians, London, that "the arthritic incidents of gout |