Pneumonia FITCHMUL Bronchial and Croupous SUCCESS ATTENDS THE USE OF FITCHMUL by thousands of physicians because its components meet all the indications for treatment in these diseases. ¶ The less severe cases yield to its influence from the outset— the more severe, as soon as resolution begins. ¶ It would be difficult, indeed, for the most rationalistic of physicians to suggest any superior combination, or one more exactly fitted to the indications, to wit: ¶ BALSAMICS as antiseptics; ¶ CHLORIC ETHER to stimulate heart and respiratory centers and tone circulation; ¶ HYDROCYANIC ACID to allay irritation of lungs and major bronchi; ¶ TARTRATE OF ANTIMONY to thin secretions— loosen them and stimulate expectoration, and ¶ AROMATICS to soothe the stomach. ¶ A FITCHMUL EPITOME of Constitution and Capacity. Recent Clinical Reports and Physicians' Samples Free THE FITCHMUL COMPANY, Concord, N.H. ALBERT ABRAMS, M. D., San Francisco. ARTHUR R EDWARDS, M. D., Chicago, Ill. Mr. REGINALD HARRISON, London, England. RICHARD T. HEWLETT, M. D., London, England. J. N. HALL, M. D., Denver. HOBART A. HARE, M. D., Philadelphia. FRANKLIN H. MARTIN, M. D., Chicago. FERD C. VALENTINE, M. D., New York. WM. H. WILDER, M. D., Chicago, Ill. LEADING ARTICLES THE TREATMENT OF THE MORE COMMON SECONDARY SYMPTOMS OF DIABETES. ALFRED C. CROFTAN, M. D. CHICAGO. MOST of the complications of diabetes disappear promptly with the reduction of the glycosuria. Sometimes a more rigid diet must be ordered for a time than would other wise be given on account of the complications, so that a mild type of diabetes, for instance, must be treated like a case of medium severity. Now and then it becomes necessary further to employ special methods for the relief of very obstinate, very distressing or particularly dangerous symptoms. STOMATITIS. The stomatitis, gingivitis, pyorrhea, the loosening and caries of the teeth may be due either to localized infections or to trophoneurotic influences. The mouth manifestations are among the most distressing symptoms of diabetes. It is important that every case of diabetes should, from the beginning, be instructed carefully in regard to the possibility of mouth complications, and taught how to obtain mouth asepsis and to perform the proper toilet of the teeth and gums. After No. 2 each meal a diabetic should rinse his mouth and cleanse his teeth, preferably with 3% solution of sodium carbonate in warm water to which may be added as a flavor a few drops of the tincture of eucalyptus or a little menthol. Mechanical irregularities of the teeth should be corrected early, preferably during the aglycosuric period. All arti cles of food that can mechanically scratch or injure the gums and very hot beverages should be forbidden. A hard tooth brush Pruritus, either general or localized, especially about the genitals, is one of the earliest, most distressing and most obstinate symptoms of diabetes. General pruritus is presumably due to irritation of the cutaneous nerves by circulating sugar. In most cases its intensity fluctuates with the degree of glycosuria and the symptom frequently disappears without further interference when the urine becomes sugar free, only to reappear again, however, when more liberal carbohydrate feeding is instituted and the byperglycemia increases. The best remedy for internal use and almost a specific is sodium salicylate, in doses of 30 grains (0.6 to 2 g.) several times a day. Local applications are of very little value in general pruritus. In pruritus around the genitals, due in many cases, to the development of fungi (mycosis vulvae), treatment directed towards the reduction of the glycosuria, sodium salicylate internally and anodyne powders or oint. ment applied locally usually relieve. A 5% cocaine ointment or 2-3 per cent eucaine ointment, or a dusting powder containing 10% of orthoform combined with frequent washing of the parts without rubbing or scratching usually promptly produce relief. DYSPEPTIC SYMPTOMS. Dyspeptic symptoms arising in the course of diabetes always call for particular attention. First, because diabetics, more than sufferers from any other disease, are depend ent for the maintenance of their existence upon an intact gastro-intestinal tract. Second, because dyspepsia, especially in severe types of diabetes is frequently a precursor and a determining factor in the development of coma. Dyspeptic symptoms not uncommonly arise from montonous one-sided feeding, e.g., from an excessive meat-fat diet, or simply from over-loading the stomach (polyphagia) with resulting functional over-taxation and mechanical dilatation. In very severe cases of gastric irritation, the best plan of all is to withdraw food completely for a period of twenty-four hours, allowing merely a little broth or diluted milk, or a little claret in water, and, at the same time, feeding the patient by rectum. In order to allay the gastric hyperalgesia and the vomiting, cerium oxalate in 1 grain doses, frequently repeated, or cocaine (2 drops of a 1% solution in one-half a glass of water, a teaspoonful every fifteen minutes) or teaspoonful doses of 2% chloroform water should be given, while either cold or hot applications, according to the likes of the patient, should be applied over the epigastrium. The severe thirst that usually appears during the period of food and drink restriction can, to some extent, be mitigated by allowing these patients to chew gum, to swallow small pieces of ice at frequent intervals or even to smoke a little. After this rest cure for the stomach, the patient should be put for a day or two upon broths, milk and gruels composed of almond meal or gluten-flour, and then gradually the broad dietary resumed, care being taken all the time that the maximum of food is introduced by rectum in order to maintain the general nutrition. The more chronic dyspeptic disorders in diabetes call for careful analysis of the gastric function and corresponding treatment, the details of which cannot be discussed in this place. CATARRH OF THE BOWEL. Catarrh of the bowel is always serious in diabetes. Acute catarrh with profuse diarrhea should be attacked most energetically in every case; for the interference with food assimilation that results rapidly weakens the patient and not infrequently precipitates coma. Bismuth subnitrate in doses of 15 to 20 grains (1 to 2 g.), with extract of opium onehalf grain, and tannic acid suppositories containing about 3 grains (0.2 g.) of the drug should be given at frequent intervals until NERVOUS DISORDERS. The majority of these nervous disorders rarely require special treatment, for they yield spontaneously if the hyperglycemia (scil-glycosuria) is reduced. The symptomatic treatment of the neuralgias is rather unsatisfactory, for the ordinary antineuralgic remedies rarely suffice to control the pain. The best combination of drugs, in my experience, is quinine and opium, given as follows: R Quinine sulphate....10 grs. (0.65 g.) Extract of opium.... gr. (0.0015 g.) gr. (0.0015 g.) In capsule repeated three or four times a day. Antipyrin, in 5 grain (0.35 g.) is also occasionally of use, especially as it seems to exercise some effect upon the glycosuria. GANGRENE. Gangrene is one of the most distressing and dangerous complications of diabetes. When it is once fully established, amputation of the affected member becomes necessary. Most surgeons recommend dressing the gangrenous extremity with a moist boric acid solution and awaiting the appearance of the line of demarcation before performing amputation. In diabetic gangrene, particularly, the amputation should be performed high up in the region of healthy arteries. With the appearance of gangrene, the diet should never remain altogether carbohydrate free. It is always better to allow from 50 to 100 g. of white bread or its equivalent. Occasionally prophylactic treatment can be instituted, especially in old people or in alcoholics, or in individuals with marked arterio-sclerosis, who complain of certain premonitory signs like continuous pain, tingling or hyperesthesia in an extremity. Here everything should be done to promote the venous back flow from the affected member. Hot foot-baths and massage should be energetically instituted, while, at the same time, every effort should be put forward to reduce the glycosuria. THE ATYPICAL, THE INDEFINITE. J. R. LANDERS, M. D. BERNADOTTE, ILL. IF each individual physician's opinion could be collected as to what class of, cases are most unsatisfactory, and for which we prescribe with least confidence we have little doubt the consensus would be that the atypical of indefinite manifestations are most vexing and are prescribed for with least certainty. The typical syndrome of the definite disease is usually readily recognized, and we are able to apply some treatment approved or prevalent and be the result satisfactory or otherwise we may feel blameless, even if uncomfortably so. But the atypical syndrome, the indefinite symptom complex not con- . forming to any type vexes and gives rise to doubt. And no less so because the patient may consider it a minor matter easily dispelled, and that any sort of a doctor ought to comprehend and cure without thought. Some will say that they have "dyspepsia, and surely it is easy to cure dypsepsia" or a cold and "it isn't any trouble to cure cold," or a cough, and "lots of people can cure a cough, and certainly a doctor can do And rheumaso magically or ought to. tism, rheumatism don't need much of anything, just something to stop the pain.' And so it goes, grave and important disturbances of the body are frequently considered of little or no consequence, and a few cents worth of medicine-"The cold conqueror,' 'cough cure," "pain preventor" and "rheumatic reversor" should each dispel the difficulties in the respective fields magically and permanently. Should the physician suggest a Magi examination to determine conditions and understand the indications he would brand himself an incompetent in their estimation, unless very diplomatically explained. cal relief is expected and frequently for all manner of departures from health representing all degrees of pathology from simple cough to hydrothorax, from discomfort incident to imperfect or incomplete digestion to organic disease of the digestive apparatus, from flatulency or colic to typhilitis and appendicitis, from simple annoyance and uneasiness in the pelvis to malignant disease of the pelvic viscera and from pruritus ani to cancer of the rectum. Doubtless every practician who has had his shingle out any length. of time can verify this statement from experience. Such has been our personal experience. We recall a malignant gastric disorder where the patient insisted it was a little indigestion of immaterial consequence, and a little digestive agent was all they needed till too late. Another, a man 30 years old, came in with the information that he just dropped in to get something to stop his cough, as it had been troubling him for several weeks, and did not seem to get any better, so he thought he would come in and get a few doses of medicine to stop it. When it was suggested an examinaion be made to discover the cause he did not think it necessary. "It was just a cough and he wanted something to stop it." When asked why he was so "short of breath," as he was breathing rapidly, he said it was caused from coughing so much, notwithstanding he had hydrothorax. We mention these cases to show the possibility of error, but we had intended to direct our attention to the more simple cases and to some remedial measures usually applicable and essential. It may be only a cough, but what shall we do for it? If we have the opportunity to observe and note the character of the cough it may solve the problem, and we may be able to see and meet the indication. But sometimes patients do not cough for diagnostic purposes, and sometimes to it may not, cannot solve the problem. There are always some plain indications, and it cannot often be amiss to clean out the internal premises and disinfect them and render toxemia less probable or less pronounced. Then the vital forces being less hampered and eliminants less taxed the normal balance may be resorted, when the cough will vanish. There may be There may be other needs. The vital forces may be depressed with function and functionating power inadequate and need help. The vasomotors may be unbalanced and cannot competently govern and maintain the circulation, and will need relaxants to overcome spasm of arterioles on the one hand and a revitalizer and constrictor to overcome paralysis on the other, or in another locality or situation. In a word, we assist in systemic adjustment. In some cases the cough continues and seems to be both cause and effect-maintaining a vicious circle the irritation caused the cough, and the cough keeps up the irritation. indication would then seem to be to stop the cough. If correct and we stop the cough by obtunding sensibility for from three to twelve hours it does not reappear. Probably such is not frequently correct practice. if the vital organs are properly functionating so far as we can see, and the eliminating crgans active and irritable cough continues, the indication is to stop the cough, by obtunding sensibility, render inoperative the perpetuating cause. And we have all seen what appeared good and satisfactory results. The But Here as elsewhere we believe in cleaning the prima via bringing up vital force and function when we have conditions most favorable to determining the weak point or the cell and somatic need. We have seen the hach! hach! hach persistently recurring every few minutes without expectoration yield quickly and pleasantly to a few milligrame doses of apomorphine to bring out secretion. And cases where there was harassing paroxysms of coughing ending up with the expectoration of a small amount-a drop or two of glairy stickly mucus as quickly yield to half milligramme doses of veratrine-or aconitine. But it is not always easy to determine the cause of the persistency of a cough, in fact it is too frequently impossible to do so. However, we are not justified in masking by obtunding with opiates longer than twelve hours. If after this the cough persists the indications were not well met and opiates are contraindicated. To stimulate the sustaining and eliminating functions with the mild chloride of mercury and sweep out the prima via with a saline laxative, disinfect with the sulphocarbolates and keep it so. To adjust vasomotor balance, poise the governing power, sustain or help sustain tissue tonicity and body balance can scarcely be amies or contraindicated. The "dyspepsia patient" is frequently a source of our annoyance and discomfort as well as his own. To put them under systematic observation may be as impractical as impossible and to diet a patient is one of the greatest difficulties it has been our misfortune to attempt-an impossibility, at least, till the condition has made the patient wake up to the facts. We likely have a patient who has had a few attacks and apparent recoveries, but now he fails to get relief or complete relief-his stomach is a little uneasy, a little pain, a little langour, a little headache, and a little appetite, or a big one, yet he is not convinced that it will require any material measures to cure him. And right here is an opportunity to apply the "clean out, clean up and keep clean method and witness the prompt and beneficial results, and also to witness the practical value of intestinal antiseptics, and the brilliant work of the sulphocarbolates as such which are desirable, decided and incomparable. We would not underrate diagnosis, undervalue its importance, nor encourage guess work or haphazard prescribing, but there are times when it may be impossible to make a clear cut diagnosis for different reason, notably among them we may mention getting the patient's assistance which may not be possible and he will not cooperate with the physician till his own time. Nothwithstanding it is never undesirable nor a non-essential, no matter where |