the necessity of regarding this disease as one of inner metabolic disturbance, the cause of which must be sought for diligently, if the patient is to be afforded permanent relief. The therapeutic measures, therefore must be directed to the cause of the disease, and not to its outward manifestations; and finally, particular attention must be given to the before mentioned minor points in the personal hygiene of the infant, which while they do not constitute causes of the disease, serve as predisposing influences and complicating fac tors. IONIZATION AND OXIDATION. BY J. P. DICKSON, Franklin, Iowa. I refer especially to the energy implied by oxidation, which according to Overton, Powell, and some almost ultra-scientific, is capable of producing, unaided, heat, motion and nerve force or mental action (ionization not included). I have seen no physiological demonstration of balanced. creation of heat in the kidneys but I have had a patient in whom the kidneys were not working (likely due to a splanchnic poison of intestinal origin) and it was clear there was complete failure of the heat making function. I applied heat externally, increasing ionization, retained heat by oils, gloves, "neckerchief," jacket, etc. and gave the fullest dose of ammonium acetate, starting kidney action, and soon had the patient safely over that "spell" (atropine was used in others). There may have been retention of carbonic acid gas in the blood, or tissues, or indeed the kidneys, so as to hinder oxidation. The skin, in a neglected condition, did not favor oxidation and was so slimy that excretion lagged. The lungs, in an engorged condition, did not favor circulation, neither of blood nor ions like gas. The treatment made use of what was left of use in the skin and it relaxed it, if the medicine did not also contract the pulmonic area of capillaries, favor the formation, or conserve the loss, of blood alkali, and furnish a little soluble food in the acetic radical. The protein molecule, less soluble, (unless it be one of serum-albumin) is, in conditions involving the lymphatic circulation, practically out of the field. I have been studying whether or not in case of vaso-constriction there is not accumulation of lymph in the periphery, and it seems it does not readily pass into venous capillaries for some physical reason, likely best seen in Draper's "Medical Physics" or Stern's "The Autotoxicoses" (see La Force on Peritonitis-Keokuk). I do not know as to circulation of colloids that lymph vessels have been traced to the stratum mucosum, or any further than the blood vessels have been traced, but I feel sure the lymph vessels are to be reckoned with and to be acted on even before the blood vessels. Porter of course was not giving pathological physiology. It may be nevertheless that oxidation of colloids in the kidneys is not normally the rule (though Nature could thus increase ionic action) but is dependent on some failure of the lymphatics in the kidneys, or more remotely, and but one poison has been claimed to affect the lymphatics—curain. I have seen no demonstration of autonomic nerve supply to the lymphatics. That the lymphatics may be affected as well as other vessels may be inferred from the presence of muscles in the thoracic duct (Howell), and may be in other lymph channels. Mercury and gold so modify lymph as to raise the question of use of lymph as well indicated. Ammonium chloride, being a sort of substitute for calomel and well known to favor absorbtion, may do so by an ionic action on or among lymph (colloid) molecules (see Rockwood's work) but it is not conserved in the system as are the metals. One writer has considered briefly the lymphatics in the kidneys and another admits failure to oxidize proteids, produces casts even when diet is merely in excess and there is no epithelial lesion in the kidneys, but he does not exclude oxidation therein no more than Porter excludes lymphatic derangement prior to oxidation. there. The derangement may begin by a chemical or physical cause and be followed. by complications such as infection or traumatism, trophic insufficiency or catabolic. retentia (even "abnormal menstruation" of "lymphogenous origin."-Med. Standard). Lymph does not show the effects of gravity as readily as serum; nor does it so readily. exude on skin. Hence its deposits are more general and more firm; but may be quite local and tough. We have, if possible, to distinguish lymph from deeper deposits of salts and consequent hydration of muscles, etc. The infections written of as being found in lymph channels and glands are numerous, typhoid, erysipelas, scrofula or tuberculosis, etc. The toxins vaguely given as affecting metabolism. are toxalbumins, diamins, leucomains, ptomaines, etc., while the graphic formula and symbolic grouping have not been presented or have not as yet suggested a chemical antagonism, nor has much progress been made in the study of chemical lesions and repair after the study of tetanus. The latest out is an effort to show puerperal eclampsia is due to a "ferment" and the clinical picture is one also of lymphatic involvement. Well, curain is not far dif ferent from a ferment. There is a certain stage in which besides subsultus tendinum there is spastic action contracting the muscles, flexing the fingers, showing that the poison acts on the spine, is the cause and not the effect of circulatory changes in the brain; that is, this may be noted in other than scarlatinal, pneumococcic and tetanic infections, and may not be a mere reflex from intestinal irritation. Between attacks there is a vague subjective symptom referred to the abdomen, which I have not traced to duct or ileum. We may owe something to non-medical treatment or means to change the circulation and so aid in resisting chemical change and its train. This point needs pressing as the lay mind is not wedded to germs and the tactful physician needs a good vocabulary just now. I opine that we must trace force much further than oxidation just as we must trace solution much further than water. Some refuse to drink water till salts enable them to use it-others drink to excess and get internal reaction, abnormal thirst, lessened kidney action. Even test tube solution is translation. Experiments in fasting show great conservation on elimination of food waste has been enriched, but dietetic error is recovered from in seldom less than three days and it takes two weeks of abstinence as to most particular articles to convince a patient of error. Always remove by surgical means a chancre of the lip. When it is considered how many innocent persons are exposed from a syphilitic sore in this location it is surprising how many physicians neglect this most important method of prophylaxis.-J. J. McKone, Int. Jour. Surgery. , 1910 , Vol. V., ful medical practice than having absolutely Joseph P. Remington. ETIOLOGY AND DIAGNOSIS. I have read with much interest your ed- Philadelphia. itorial articles on pp. 549 and 550 of the November issue of the magazine. There have been so many articles written on the Pharmacopeia from a medical standpoint which have been misleading or which show but a one-sided view of the subject that I can assure you I read your article with much satisfaction. The Pharmacopeia has reached such a position as a national authority and law book since the passage of the Food and Drugs Act that past history will help us but little. It is the present and future status of the book which should have exclusive consideration. I have seen no indication on the part of pharmacists, chemists, or pharmacologists to exclude the medical profession from helping to the utmost and it is the prerogative and bounden duty of physicians to have the greatest weight in the coming revision in deciding upon the articles which are to go into the Pharmacopeia and those which are dropped; and of course it would be absurd to place the responsibility of the doses upon any other than the medical profession. What is needed more than anything else is harmonious co-operation and the question of "who is greatest" can well be left to the historian of the next century. Some of your editorial remarks, strangely enough, bear particularly upon the "Coudrey Bill" just introduced into Congress. This bill provides for the standardizing of every medicinal substance whether used for men or other animals. Chemistry and pharmaceutical chemistry have not advanced so that this is possible and centuries will be required before this can be done. We will have to depend for many tests of identity and purity upon other means than standards and quantitative tests. The Food and Drugs Act has wrought marvellous changes in the quality of medicines. Adulterations and sophistications are being weeded out with great rapidity and what can be more conducive to success The Diagnosis of Ulcer of the Duodenum.1- Codman presents the following résumé of his observations: In the development of mammals the large intestine is swung across the small, thus necessarily the whole blood supply of the small intestine and most of the large must cross the small intestine. This crossing place occurs at the end of the duodenum beneath the superior mesenteric artery. But in horizontal quadrupeds no obstruction is produced at this point, while in vertical man a greater or less obstruction must necessarily be thus produced. As a result of this obstruction in man the secretions of pancreas and liver may at times be thrown backward on the first part of the duodenum, the first part of which is unfitted to withstand long continued action of these secretions, since its mucous membrane is histologically and developmentally different from the rest of the duodenum and is more closely allied to that of the stomach. The action of these caustic secretions on this unprepared mucous membrane may give rise to irritation accompanied by certain painful sensations, which may be felt in the epigastrium and attributed to the stomach. Long continued action of this kind may, under certain conditions, lead to erosion and even deep ulceration of the mucous membrane just below the pylorus. Such ulcerations, when they are close enough to the pylorus, lie in the folds of mucous membrane just outside it, and are comparable to fissures of the anus, and, like fissures of the anus, they are kept from healing by their relation to the sphincter. Clinically, hunger, pain, and dyspepsia are the primary symptoms of such ulcers or fissures, and certain other 1E. A. Codman, M. D., Boston Med. and Surg. Jour., Nov. 25, 1909. clinical phenomena are secondary symptoms. In the diagnosis of these cases mistakes are made by too great consideration of these secondary accidental symptoms and too little attention to the primary insignificant hunger pain and indigestion, and when these considerations are taken into account, the diagnosis is really not difficult in the advanced cases. Ulcer below the pylorus is more common than it is above, and in future we must make diagnoses of duodenal or possible gastric ulcer instead of the vice versa. Duodenal ulcer is nearly as common as acute appendicitis. TREATMENT. Senile Dyspepsia. The treatment of senile dyspepsia is essentially the same as that adopted in the allied conditions of achylia gastrica and atrophy of the stomach. Mastication must be performed in an efficient manner, and new teeth should be inserted when necessary. The state of the mouth requires careful attention, and a wash composed of Condy's fluid, boric acid, or other antiseptic should be employed after each meal. Special precautions must be taken to protect the patient from exposure to cold, and it is advisable that a woolen or flannel belt be worn next to the skin of the abdomen both summer and winter. Fluids always increase the tendency to flatulence, and consequently beef-tea, broths, and soups should be avoided, and only a small quantity of hot water be allowed at the end of the principal meal. Tea always disagrees, and the various sweet preparations of cocoa are apt to excite gastric fermentation; but a palatable beverage may be prepared from the cocoa nibs or husks. Some individuals are able to take coffee without discomfort. The addition of a tablespoonful of brandy or whisky to the hot water taken after meals is often of value in allaying the epigastric distention, but wines, malt liquors, and effervescent drinks must be avoided. Raw milk should be prescribed with caution, and in most cases it requires to be diluted with lime-water, mixed with citrate of sodium or peptonised, before the 1 W. S. Fenwick, M. D., Lond. Lancet, Nov. 6, 1909. , 1910 , Vol. V., patient can digest it. The fact that subacidity always exists renders it necessary to restrict the diet to finely minced white fish, chicken, game, brains, tripe, sweetbreads, calves' feet, eggs, and scraped or pounded raw meat. pounded raw meat. Green vegetables and raw fruit always increase the indigestion, but cauliflower, seakale, stewed celery, and asparagus may be given in moderation, or a baked apple may be taken with the midday meal. Toast is preferable to bread, while buns, cake, and pastry must be prohibited. Fats may be allowed in mild cases and cod-liver oil is often of much benefit, but in advanced cases fatty substances are apt to produce nausea and diarrhoea. The various digested and semi-digested cereal foods, maltine, and sanatogen help to vary the diet, but barley, oatmeal, and rice must be given with caution. The main indications for medicinal treatment are to correct the subacidity and to relieve the flatulence and constipation. For deficient digestive power of the stomach it is customary to prescribe dilute hydrochloric acid after meals in combination with pepsin, papain, or other artificial digestives, but when given in the ordinary way the mineral acid seldom produces any good effect, while pepsin and its allies are useless. A better plan is to administer 6 ounces or more of a 0.05 per cent. solution of hydrochloric acid, combined with one and a half drachms of glycerine, twice a day after the principal meals. As a rule, the best aid to gastric digestion is to be found in the administration of lactic acid bacilli in the form of Metchnikoff's sour milk. If this is properly prepared and a tumblerful be taken with the meals each day many of the dyspeptic phenomena vanish after about a fortnight and the flatulence is greatly relieved. According to my experience the various tablets composed of lactic acid bacilli at present on the market are of very little value. Maltine and takadiastase are chiefly of use when intestinal dyspepsia exists and should be given with the meals. Tonics always increase the flatulence and even the various bitters prescribed with the view of stimulating the appetite usually disagree after a few days. In order to relieve an attack of flatulence a draught containing ammonia, ether, and spirit of cajuput is usually employed, but a far better remedy is to be found in the New Series, Vol. V., No. 1. HYGIENE AND DIETETICS alcoholic essence of peppermint introduced by Ricqlès and now obtainable at most of the large chemists in London. One teaspoonful or less in a sherry-glassful of water seldom fails to relieve the feeling of distention or an attack of wind colic. For the constipation, salines and mineral waters should be avoided and recourse be had to a mixture of cascara and maltine, a confection of sulphur and guaiacum, the infusion of senna pods, or to an occasional dose of grey powder. The Treatment of Abortion.1-In concluding a very complete and comprehensive article, Stowe calls particular attention to the following points in the treatment of abortion: I. The importance of treating all cases of uterine haemorrhage accompanied by intermittent pelvic pain in a woman of childbearing age as acute abortion. 2. The value of absolute rest in bed in the treatment of threatened abortion until all pain and bleeding have ceased. 3. The necessity of saving as much blood as possible to avoid a long period of anæmia and prostration. 4. The selection of cotton pledgets in lieu of gauze strips as a material for vaginal tamponage. 5. The use of finger curettement and manual removal of the uterine contents wherever possible. 6. The performance of Hoening's abdomino-vaginal compression when the conditions are present. 7. The difficulty of complete sterilization of laminaria tents. The danger of perforation of the uterus with steel dilators and sounds. 9. The great danger of uterine perforation with the steel curette in acute abortion and the value of the instrument in chronic abortion. 10. Curettement should be raised to the dignity and seriousness of a surgical operation and should be performed under the same surroundings and with the necessary equipment. II. The importance of refraining from curetting after the complete emptying of the uterus. 'H. M. Stowe, M. D., Chicago, Surgery, Gynecology and Obstetrics, Jan., 1910. 12. empty. The use of ergot after the uterus is 13. Local interference in septic abortion when the infection is limited to the uterine cavity. Less tendency to interfere when the septic process. adnexa or peritoneum are involved in the HYGIENE AND DIETETICS. Oxygen Baths.1-Efforts have been made for several years past to impregnate water with active oxygen, and many means have been employed, but without much success, until a firm of manufacturing chemists conceived the idea of using sodium perborate, which, as is well known, has an unusually high content of available oxygen. Under the name perogen bath this is now on the market, and after an examination by the council on pharmacy and chemistry of the American Medical Association has been admitted to the list of accepted remedies. Perogen bath is described as a preparation borate capable of yielding ten per cent. of consisting of a catalyzer and sodium peroxygen, the two substances being wrapped separately. When the two substances are medicinally indifferent substance, causes the mixed with water the catalyzer, which is a sodium perborate. The oxygen bath thus liberation of the available oxygen of the obtained is said usually to reduce blood pressure and the pulse rate to a much greater extent than the ordinary bath. It is represented to have marked tranquilizing and somnifacient effects. It is asserted to be useful in cardiac affections with high vascular tension and excitement, neuroses, insomnia, chronic nephritis, and skin diseases in which hydrogen dioxide is indicated. It is recommended to be given daily up to twenty-four or forty-eight baths, with occasional intermissions. The Diet in Typhoid Fever in Children.2 Children stand starvation diet typhoid fever. Even under the most favorbadly; it has no place in the treatment of able conditions there is bound to be a loss of energy, and unless the nutrition is sufficient for all of the child's needs there will 1 New York Med. Jour., Dec. 11, 1909. 2 Le Grand Kerr, M. D., Am. Jour. Obstetrics, Nov., 1909. |