indicated by this type of prescription, it was found that the average dose of hydrochloric acid was from three to five minims, very rarely ten, and never more. Let us ask what was the idea in prescribing these minute doses of acid? Evidently not to make good a physiological deficiency, for to that they were entirely inadequate. Why, again, was the acid never given alone, but almost always in conjunction with pepsin, and not infrequently in conjunction with pancreatin? Is it not generally known that full doses of hydrochloric acid, given threequarters of an hour or so after meals, is all that is required to convert the nearly always present pepsinogen into active pepsin? Evidently it is not acted on.

Neither did these 25,000 prescriptions give any evidence of the present state of knowledge concerning Hyperchlorhydria. It is a very common disease, but its treatment by the exhibition of full doses of sodium bicarbonate or other alkalies, two or three hours after meals, was conspicuously absent. The use of the dietetic treatment by the prohibition of the starches and the prescription of albuminoids could not be determined from the directions, but men in consulting practice will, I believe, agree that it is not common.

Another marked feature of these prescriptions was the small use made of intestinal disinfectants, notwithstanding that the constant occurrence of the symptoms of intestinal intoxication ought to suggest their frequent employment. Perhaps the most marked feature of this investigation is the evidence of the preponderant use of artificial aids to digestion. A use clearly out of all proportion to the requirements of a correct therapeusis. A use that amounts to an abuse; and, when long continued, harmful in the extreme. What would be thought of a surgeon who kept a limb in splints until muscular atrophy was established? Yet it is not uncommon for digestants to be given until muscular atony and glandular atrophy have permanently injured a merely funcTM tionally disordered stomach. Egrescit medendo.

Lastly, to what extent is the effort made to diagnosticate intestinal from gastric dyspepsia? The former is quite common. It requires different treatment, but the prescriptions examined give little indication of its recognition. Ox gall, for instance had no place therein. Leaving on one side the unjustifiable reliance on proprietary articles, which in itself excludes 65 per cent of the prescriptions from a place in scientific medicine,

taking no note of the not infrequent examples of chemical incompatibility, there still remains a residuum in which we ought to find an acknowledgment of the status of modern physiology and pathology. We can only say that if the knowledge exists, it is not in evidence.

EARLY DIAGNOSIS OF BRIGHT'S DISEASE BY INCREASED ARTERIAL TENSION BY GAERTNER'S TONOMETER.

By ALFRED W. PERRY, M. D., San Francisco, Cal.

The early diagnosis of that form of Bright's disease known as interstitial nephritis, or more commonly as contracted or gouty kidney, is of extreme importance, and at the present time there is no symptom relied on as much as a high tension of the pulse. It is always associated with hypertrophied heart and arterio-capillary fibrosis, of which, in fact, the kidney disease is only a local manifestation. Probably a very small fraction is diagnosticated until a few months before death.

Its Frequency.-Sir W. W. Gull and H. G. Sutton', from an examination of 357 cases dead from various causes, found chronic granular nephritis in—

Mohamed', in 150 persons dying in Guy's Hospital:

Sam West', in 79 autopsies at St. Bartholomew's Hospital, found 48 per cent with chronic interstitial nephritis, and that it caused death in 33 per cent. The general mortality of cities in the cool temperate zone gives a rate of 4 to 5 per cent of the deaths over 40 years of age.

San Francisco' in 1889 and 1890 had 5026 deaths in persons above 40 years of age; 203 of these, or 4 per cent, were of chronic Bright's disease.

In the tables above given by Sir W. W. Gull, Mohamed and Sam West, 40 per cent of the decedents above 40 years of age had chronic interstitial nephritis.

From the hospital reports above given we find that about 40 per cent had granular contracted kidneys. We may infer that only about one tenth of the deaths due to chronic Bright's disease are diagnosticated as such in persons over 40 years old, from the absence of classical symptoms.

In view of the long latent period of the disease there has been a great effort to discover some early reliable symptoms. Those which have been relied on, and have been mostly successively abandoned, are: Albuminuria, epithelial casts, low specific gravity of urine, low daily excretion of urea, increased toxicity of urine when injected into rabbits, diminished amount of phosphates, 'high tension of pulse, "reduction of freezing point of urine.

Albuminuria occurs in young and healthy adults (3 per cent), and is so often absent until near death in chronic kidney disease that it has no value as an early symptom. Pierre Jeanneton of Prof. Dieulafoy's clinic, in a monograph on albuminuria, says that the chemical composition of the urine in chronic Bright's disease has lost almost entirely its clinical significance; the microscopic examination has not much more value.

Increased toxicity of the urine when injected into animals was proposed by Bouchard; it has some value, but is not available clinically. That albuminuria nor dropsy exist habitually in chronic Bright's disease is sustained by Mohamed", Millard", Delapierre of Paris, Dieulafoy", Prof. Lepine" of Lyons. When such an important organ as the kidney is extensively diseased we naturally look for an alteration of its secretion, and, not finding it, we are inclined to pronounce the organ healthy. The reason for the absence of alteration of the urine, where the kidney has probably been diseased for years, I will endeavor to explain.

All organs of the body have a large reserve power of from two to ten times their action in moderate conditions of exertion, eating, changes of temperature, etc. The kidney secretes ordinarily 1500 cubic centimeters of water per day. In excessive beer drinkers, and in diabetes melitus and insipidus, it has risen to 12,000. The excretion of urea for a man of 65 kilos (143 pounds) on a mixed diet is 20 to 26 grammes daily. Lehman",

in experiments on himself, found the excretion on an animal diet 59 grammes urea daily. Vogel" reports observing a case of typhoid fever with a daily excretion of 80 grammes urea.

The above observations show that the kidneys under ordinary conditions of health and mixed diet are working to only onethird of their capacity, and that two-thirds of their secreting tissue may be destroyed without decreasing the urea excretion below a normal amount. Physiological experiments on animals give the same conclusions. J. R. Bradford" (Gulstonian Lecture, 1899), found that in dogs from which one and a half kidneys were removed the excretion of urea was normal and the animal lived a long time. When more than three-fourths of the renal tissue was removed the animals quickly died.

Decrease in the phosphates under the name of oligo-phosphaturia was proposed by C. W. Purdy" in his work on urinalysis; they undergo great variation in health, and are diminished in many chronic diseases.

High tension of pulse, with detection of blood coloring matter in the urine by ozonized tr. guaiacum was first strongly insisted on by Mohamed". The guaiacum test has not been found useful, but the high blood tension is now recognized as the best and earliest symptom of granular kidney. The rec. ognition of increased arterial tension by the finger depends too much on practice and individual delicacy of touch, and a number of instruments have been devised to measure this exactly, of which the tonometer of Prof. Gaertner of Vienna is the latest, simplest and best-first used in October, 1899. It consists of a brass ring one inch in diameter and one half inch wide, with a short brass tube one-fourth inch in diameter connected to the side of the larger ring; inside the large brass ring is a thin rubber tube seven-eighths inch in diameter, the ends of which are tightly tied over the outside of the brass ring; this is connected by a T-shaped rubber tube with a gauge showing pressures up to 250 millimeters of mercury and with a closed rubber ball of 100 cubic centimeters capacity. It is operated as follows: The brass ring with the thin rubber lining is slipped over the finger of the person whose blood pressure is to be tested to about the middle of the second joint; then a tight rubber band or ring is rolled up the finger to the brass ring. This makes the finger anemic. The rubber bulb is compressed until the mercury gauge shows a pressure of 200 millimeters, when

the ring is rolled off the finger. The finger remains anemic from the pressure of air in the rubber-lined brass ring. The pressure is allowed to drop slowly by relaxing the pressure on the rubber air bulb until the finger commences to become pink, and the pressure indicated by the mercury gauge is read off. The pressure of the rubber-lined finger ring prevents the blood flow into the finger until it is a little less than the pressure of the blood in the arteries, which is normally from 100 to 130 milImieters. When provided with a metal gauge like a small

aneroid barometer it becomes a very portable instrument, and of the greatest value in the diagnosis and prognosis of other diseased conditions. In diseases of the heart it is a most important guide as to the effect of treatment as a means of prognosis before serious surgical operations, especially those for removing one kidney. Low tension of the blood pressure in cases of albuminuria robs them of their threatening appearance.

The blood pressure in healthy young persons is from 100 to 130 millimeters of mercury. Anything much above 130 indicates some obstruction of the circulation in the capillaries. It may be due to lead poisoning, insufficient oxygenation of the blood,