they leave the sanatorium-school. I may venture to say that after a course of three weeks in such an institution, a patient will be well able to take care of himself no matter where he may go to continue his treatment for an ultimate cure. Furthermore, by these instructions, infection to other persons through ignorance and carelessness will be made almost impossible. We know that the untrained and uncared for consumptive constitutes a great menace to his home and work-shop. Very frequently he causes additional lives to be sacrificed because his presence and his ignorance constitute a dangerous environment for his associates. The laity is beginning to learn that it is no longer necessary to go to the mountainous regions to seek a cure for tuberculosis. We know that pure air is the most essential requisite and wherever we can find it constantly we are reasonably sure to obtain quick results in the treatment of tuberculosis, provided the patient has an intelligent understanding regarding his disease, or is under the supervision of a trained physician. It may interest you to know that in every locality where sanatoria for consumptives are maintained the mortality from tuberculosis has markedly decreased among the villagers since the establishment of such institutions. The reduction in this mortality is to be explained by their imitation, voluntary and unconscious, of the cleanliness and sanitary precautions practised in the institutions in their midst. Since a sanatorium has such a good influence upon the inhabitants outside the institution what are we to expect from those inhabitants inside the institution who are anxious to be cured? A graduate from a sanatorium-school will be able to go to any locality in the vicinity of his home where he can find pure air. He may even remain in his very home where he may frequently be seen by relatives and friends who will inspire him with the hope and confidence so essential to the consumptive. Thus, this intelligent near-at-hometreatment proves more advantageous too in that it does away with the homesickness and worry which are so often a great hindrance to recovery. To accomplish the object of our present labors we must infuse a fresher life into the public spirit and appeal to the humane elements in society, to feel, think, labor more earnestly, and above all not to place the entire burden upon the doctors alone. If we contemplate the nature of world-evolution we find that it consists in a leaning of the higher toward the lower, which the higher attracts after having first filled it with its power, its life-that it consists in the extension of the participation of all mankind in the same bread and the same wine. Thus the phenomenon of the regeneration of the world manifests itself, even in our days, in the stir of the political life of the free. This consciousness must be roused in every man and every woman so that those more favored on earth will unite in the active work of making the poor consumptives hopeful and happy and of increasing their chances of recovery. And this great work can be accomplished best by the establishment of sanatorium-schools for consumptives. 432 East 84th Street. SURGICAL HINTS. In acute posterior gonorrhea with frequent urination and all portions of the urine cloudy, if these symptoms do not respond to irrigations of the bladder, gently massage the prostate-the expression of pus will indicate repeated massage as the treatment to be pursued.-Amer. Jour of Surgery. THE PHYSIOLOGICAL ACTION AND THE STANDARDIZATION OF DIGITALIS. BY DR. OTTO HENSEL, New York. Adj. Attending Physician, German Hospital, N. Y. Digitalis is unquestionably one of the most important drugs we have, inasmuch as it is possessed of a definite physiological action which only rarely fails in the proper cases. With a better understanding of the mechanism of the heart action, the proper indications and contraindications are clearly defined and despite active pharmacological research, no satisfactory substitute has been discovered. Briefly stated, digitalis stimulates the pneumogastric nerve centrally and peripherally, causes constriction of the peripheral blood vessels with rise in bloodpressure and probably also constricts the coronary vessels. Its most important action, however, is its increase of the irritability, force of contraction and tonicity of the cardiac muscle, with slight diminution of conductivity. The indications and contraindications can be very easily deduced from this physiological action. Thus, digitalis is useful in broken compensation and acute dilatation and occasionally in persistent tachycardia. The condition of the heart muscle should always be carefully investigated, for with pronounced fibrous or fatty changes, the drug may not only be ineffective but actually harmful. This applies particularly to cases where the myocarditic changes affect the atrioventricular muscle bundle described by His leading to the condition known as heart-block. The conductivity is here dis turbed so that not every auricular contraction will reach the ventricle, and digitalis will aggravate the condition since it still further lowers the conductivity. In cases of coronary sclerosis, digitalis would a priori be unsuitable because it tends to contract the coronary vessels, but this action can be overcome by the simultaneous administration of such vaso-dilators as the nitrites or diuretin. In cases of arythmia. due to disturbances in the auricles or sinus region, digitalis should be employed with caution, but in the condition of auricular paralysis, described by Mackenzie "nodal rhythm" excellent therapeutic effect has been seen. It is evident that it is no longer sufficient to say that digitalis is a heart tonic, but that every case must be carefully analyzed by venous tracings, orthodiascopy and, if possible, by the electrocardiograph, before the drug is prescribed with the expectation of doing good. as The study of digitalis has always fascinated pharmacologists, yet, despite a fairly large literature, the authorities are not yet agreed as to the active constituents. It seems clear, however, that digitoxin, digitalein and digitalin are distinct glucosides which all exert an action upon the heart, while digitonin is of little value and is apt to derange the stomach. The glucosides are combined with tannic acid which makes them more acceptable to the stomach. Within recent years the tendency has been to supplant crude drugs by their active principles and in many instances this is no doubt a great advantage since it permits more accurate dosage and more rapid action. Thus, quinine is now used more often than calisaya and strychnine in preference to nux vomica. With digitalis, however, the conditions are more complicated, and the question of the most suitable preparation had to be solved in another way. Inasmuch as all three potent glucosides possess a distinct action upon the heart, the full digitalis effect cannot be obtained by prescribing only one. Furthermore the free glucosides never agree as well with the stomach as the tannic acid compounds present in the native drug. The use of the isolated glucosides would be imperative only where hypodermic medication is necessary, but even here we have a more potent and more rapidly acting drug in strophanthin, especially in its purified, crystalline form. While therefore the full effect of digitalis can only be expected when the drug itself or one of its preparations is prescribed, there are obviously many disadvantages, which have only recently been overcome. Much depends upon the care exercised in collecting the leaves. In the case of certain drugs, such as cinchona bark, careful cultivation has increased the percentage of active ingredients, but with digitalis, a more potent drug is obtained from the uncultivated plant. Other precautions are also necessary, thus leaves from a hilly region should be preferred and the time of gathering should be just before flowering. After long periods of rain, an inferior grade will be obtained and adulterations are quite common. The sins committed by the pharmacist may also be numerous. The drug may be exposed on his shelves to light and air or may be over a year old. In case of the powder, it is difficult to determine if the almost inert stems and ribs are present and adulteration with inert substances is very easy. As long as no accurate pharmaceutical assay is possible, it follows that the strength of the drug and of its galenical preparations will vary within wide limits. It is thus clearly evident, that many clinicians prefer the ad ministration of the active glucosides despite their obvious disadvantages. The choice of the most satisfactory galenical preparation has caused considerable discussion. In Germany, preference is given quite generally to the powdered crude drug and the infusion. If proper care has been exercised in collecting and preserving, the results obtained with the powdered crude drug are certainly satisfactory, except that the deranged stomach of patients with heart disease very frequently will not tolerate it. In the infusion, as prepared according to the United States Pharmacopoea, water is used as solvent. The resulting preparation will not represent the entire drug, since the full extraction of all the glucosides requires alcohol. Herzfeld therefore recommends the addition of some alcohol before the leaves are strained out. Many druggists have no conscientious scruples in preparing their infusion from the fluid-extract, though an inferior preparation will thus result. The fluid-extract and tincture have been found to vary within very wide limits, even when obtained from reliable manufacturers. The dried extract, when prepared at a low temperature and from full-strength leaves is considered by many the most satisfactory preparation. It follows from the above that digitalis is a potent drug, preferably used as such or in the form of one of its preparations. The potency of every new preparation is, however, an unknown factor until the degree of reaction on part of the patient has been determined. By means of a special process it has become possible to extract the tannic acid compounds of the active glucosides, minus. the harmful digitonin and inert matter. The same idea has already been followed in removing inert matter from other drugs, such as licorice juice and ox-gall (succ. liquir. dep. and fel tauri dep.). Methods have also been described to remove gastric irritants from extract of cascara and senna leaves. It only remained to standardize the extract and this could be successfully accomplished by the physiological experiment on the frog. It is well known that after a sufficiently large dose of digitalis glucosides, the heart of the frog will cease beating, owing to systolic arrest. If frogs of the same size and species are employed, this reaction is quite uniform and hence better suited than any quantitative assay to determine the strength of any given preparation. An ideal preparation of digitalis would therefore be an extract containing all the active glucosides, freed from digitonin and inert matter and standardized by means of the physiological experiment so as to be always uniform. A preparation of this kind, extensively used by the author, is digipuratum, which has been so standardized as to be the equivalent, weight for weight, of the best powdered digitalis. Its dose is therefore the same as that of strong powdered digitalis itself. The results obtained by the author with. digipuratum in hospital and private practice, have been eminently satisfactory, in fact all that the theoretical considerations of this drug would lead one to expect. Patients with heart disease frequently suffer from congestive catarrh of the stomach, but the administration of digipuratum never aggravated this or provoked vomiting, probably because the drug is insoluble in the gastric juice and not absorbed before it reaches the intestines. The action is very prompt and reliable and the effects on pulse and flow of urine are apparent much sooner than after other preparations. The most important property of digitalis, to increase the tonicity of the heart muscle is especially apparent and cumulative or toxic effects, so commonly described, were virtually absent when given to the proper cases. Where no extensive myocardial changes were present, the edema, ascites and congestive catarrhs of the stomach, intestines and lungs rapidly disappeared. Many patients who could not tolerate any of the other preparations of digitalis, were soon benefitted and many who formerly did not react, soon showed the effects of improved circulation. Toxic symptoms were not noticed, if the usual care in prescribing digitalis was observed, and owing to the fact that digipuratum is a drug of definite potency, its action could at all times be accurately controlled. When the vasoconstrictor effect is not desired, digipuratum may be combined with diuretin like digitalis itself. Digipuratum is supplied very conveniently in tablets, each corresponding to 11⁄2 grains of best digitalis leaves. As a rule, 12 tablets are sufficient for one course of treatment. Thus, 4 tablets may be given. the first day, 3 tablets the second and third. day 1⁄2 hour after meals and 2 tablets the fourth day. The dose must however frequently be determined for each individual case and, if necessary, the treatment should be repeated after a few days' rest. The following formula is especially serviceable where there is dyspnea with scant flow of urine: R Dionini ..grain 4-2 .gr. 12 .gr. XV Sig. One powder four times a day. , 1910 Series, Vol. V., EBERHARD W. DITTRICH, M. D., Instructor in Diseases of the Skin, New York Ladies and Gentlemen: It is indeed, with much gratification that I greet you, members of the Yorkville Medical Society and open the first regular meeting of our organization. I can offer no more fitting expression of our purposes in organizing our society than to quote the preamble of our constitution, "We, the charter members of the Yorkville Medical Society, in order to promote 1Address of the President of the Yorkville Medical Society. the interest of Medical Science, mutual helpfulness in our medical duties, and more perfect friendship and fellowship among our friends and colleagues, organize this society." As many of you know, there are several medical societies, on the east side of our city. The lower east side has two separate and independent ones, while the Harlem Medical Society prospers to the north of us. Between these, are our friends and neighbors, and as near as we can learn, within the boundaries prescribed by our constitution, we have 380 physicians who had no local society where they might learn to know their near neighbors and profit by their mutual helpfulness. With some vanity, I confess my own labors in forming our society, but I credit others with earnest, splendid work in the perfecting of our association, and it is a matter of sincere pride that I find myself associated with these men, and that, in their judgment they selected me as the executive head of our society. It is true, that we are in our infancy as a society, but we will grow strong and great, for, with the wise guidance of those men who have formed the nucleus of our organization, we can make no error; while the singleness and sincerity of our purposes, will draw the best in our locality to our membership. We solicit no one to join. us, yet we offer welcome to those physicians who live within our boundaries, and who will earnestly co-operate with us in furthering our purposes. No member must feel stranger among us, nor be fearful that his efforts will be unkindly considered. The weak we wish to make strong; the strong, bold, and every member must feel, that while others may differ from him in their medical conclu |