riage license. The bill aims especially at tuberculosis, mental unsoundness, and dipsomania. It will be admitted quite readily that the public is not yet prepared to act upon the advice of medical science respecting the gravity of ill-considered marriages, and that the bill of the Ohio gentleman will never get beyond the committee in which it was promptly buried; but this measure has an educational value, and as such, should at least be spoken of by those who recognize the importance of progress in this direction, with seriousness. If the medical profession hopes to see its advice given in private accepted seriously it cannot afford to join in the public ridicule of any step in this direction, however small may be its chances of success or however undesirable may be the form in which it is presented. Medical science today requires of its exponents that they insist upon a bill of health before the marriage contract is sealed. This education should be carried on along both general and specific lines; general, through the regular channels for expressions of opinion on problems affecting the public welfare, and specific, wherever the family physician properly can offer his advice. THE REPROACH, OF ILLINOIS AND The State Board of Health of Michigan complains that graduates of the Independent Medical College of Chicago are constantly being registered in that state. They confess their inability to prevent such registration under the present medical practice act of the state. Perhaps in no branch of legislation has more educational work been done within recent years than in that respecting the relation of the professions to the state, and particularly the medical profession, and it must be recognized as a surprising condition of affairs that these two progressive commonwealths have remained stationary while others have made marked and commendable advances. A law that in Illinois permits the existence of such a notorious fraud on medical education and on public confidence as is this institution styling itself a "college" and a law which in Michigan permits the graduates of such frauds to be registered as medical practitioners are a reproach to the whole people of both states. It cannot be that another legislative session in either state will be allowed to pass without a correction of these defects. EFFECTIVE SANITATION. It is gratifying to note that the people of the United States are beginning to appreciate the fact that sanitary precautions, like charity, should begin at home. This is the kind of sanitation that will prove effective in the prevention of disease. In a number of states within recent years there have been formed state healtu bodies whose membership comprise county health officials coming together to confer respecting sanitary problems and the most efficient methods for enforcing sanitary regulation. As yet this movement has not extended throughout the entire country. That it does so extend, and with the least possible delay, should be made a special duty by the medical profession. An important step in this direction would be to separate, in those states where the undesirable condition still exists, the duties of the State Board of Health from the duties of a board of medical examination and registration. The examining board will be cheerfully supported by the profession; but the board of health should be supported by the state, and should be free from all obligations except those relating to the health of the people of the state. With an efficient State Board of Health organized on proper principles, the establishment of local agencies which will supplement the work of the state body, will be rendered easy. Effective sanitation will never be accomplished until every county has been heard from. SPIRITUALISTIC MEDIUMS VS. PHYSI CIANS. The A new competitor is in the field of medicine. It does not take upon itself a definite form as does homeopathy, Christian science and osteopathy, but appears on the field of action in the mystery of spiritualism. spirits of physicians of renown who lived in years gone by are now writing perscriptions, thereby coming in direct competition with the medical profession of this age. Should a registered pharmacist fill such a prescription? and who is responsible for the effect of the remedy? are questions that will naturally arise. Surely competition among living practicing physicians is sufficient in itself without calling upon the spirits of our medical forefathers. Take, for example, a woman suffering from puerperal hemorrhage and a kind neighbor calls upon the spirit of Esculapius to prescribe and the honored spirit prescribes "puking, purging, and bleeding;" in the light of our present knowledge what would be the prognosis? THE ROWELL TRICK. The Rowell Advertising Agency of New York recently addressed letters to a large list of medical journals requesting advertising rates and inquiring if the advertisement of "Ripan's Tabules" would be accepted. The publication of the responses in its organ, Printers' Ink, by the Rowell agency would seem to indicate that the entire proceeding was a trick designed to furnish something on the sensational order for its little organ. Among the journals credited with responses favorable to the acceptance of the advertisement appear the Journal of the American Medical Association, the Medical News, the Medical Standard and other journals which have pursued a more or less discriminating policy toward nostrum advertisements. The inclusion of this journal in the "favorable" list shows either inexcusable carelessness on the part of the compiler or deliberate falsification. The reply of the publishers to the agency's letter was as follows: "The Geo. P. Rowell Advertising Agency, New York City. Gentlemen:-In response to your favor of recent date, stating that the Ripans Tabule Company is considering the advisability of advertising in our journal, we beg to state that, in accordance with our established policy, we could not consistently accept this business. "G. P. Engelhard & Co." This investigation into the character of American Medical journals by the Rowell agency was a case of false pretense from the start and, taken in connection with its untruthful report, reflects little credit on the honor or honesty of the concern which may well be regarded hereafter with suspicion by the medical press. SHOULD MINISTERS PAY DOCTORS? Nay, rather let us put the query-why should not ministers pay the doctor? There was a time when the shepherd of the flock labored among his fold and received neither gold nor silver, but lived off the hospitality of his followers. The farmer gave him grain and vegetables, the miller gave him flour, the shoemaker made him his shoes, and the doctor gave of his skill and medicine with grace according to the needs. To-day the minister receives an income equal to the average physician, and far exceeding that of the young practitioner. The minister adapts himself to this new condition, but does not discharge the obligations of the farmer, the miller and the doctor. His income may exceed theirs, yet donations, half rates, and perquisites are still not only acceptable but expected. "I never paid but one doctor bill in my life and I have never been to that doctor since," said an aged divine who for the past twenty-five years has received a salary of not less than $2,000. Yet it is not unlikely that in his family more than one physician has given of his time and skill who did not have a cash income of half the amount of the minister's salary. Why should not our ministerial brethren be consistent in their business relations with their fellow-men as they would have them be in the spiritual life? PREVENTION OF YELLOW FEVER. In order that yellow fever may be safely controlled it is essential that we gain a clear conception of its infective nature. We know that in its infective tendencies it is classed with typhoid fever and cholera as an indirect contagion, i. e., that the germs must first pass through an intermediate stage in water, milk, soil, clothing or the like, before it can infect the healthy being. Direct contagion, such as we see in syphilis, cannot be denied but it is certainly very rare. It is doubtful if the yellow fever germ infects the organism through the alimentary tract; but it is demonstrated by Sanarelli that the etrium of infection may be the respiratory tract. We are still in the dark as to the excretion of the germ, but it is likely that all diseased excretory organs do excrete the germs; this would include the stomach, intestines, liver and kidneys. Not until it is known what excretions contain the germ can we hope inthe telligently to combat disease. Heat, moisture, calm weather, and foul air are the conditions most favorable to the development and spread of the contagion. Yellow fever is pre-eminently a filth disease. Cleanliness is therefore of prime importance in its prevention, and it is to be applied to the air, water, drainage, sewerage and scavenging. It is not enough that sanitary conditions prevail during the epidemic; they should exist throughout the year. When yellow fever is first diagnosed no time should be lost in removing the infected patients to an isolated hospital and the healthy exposed occupants of the house to an isolated camp where they can be guarded and watched for not less than one week. In the meantime the house can be thoroughly disinfected. It is never wise to leave the exposed individuals in the infected house, even though the house and inmates be quarantined. All excretions, including the hemorrhagic discharges, should be promptly disinfected. IMMUNES FOR CUBA. Much is being printed in the sectarian prints about raising an army of yellow fever immunes who shall lead the invasion of Cuba. There appears to be a vast deal of popular ignorance on this subject. Only those who have successfully passed through an attack of yellow fever are pronounced by medical experts to be immune from its ravages, and there are not in the whole country anywhere near 10,000 such men. The impression which seems to prevail that men from the southern states are not subject to infection is absolutely erroneous. The resident of Louisiana will acquire the disease as quickly as the citizen from Maine, under equal conditions. Our soldier boys, from whatever section recruited, are willing to face the dangers of disease with the same unflinching courage that they would face the guns of the enemy, and those in authority should not commit the serious error of asking the sons of any one section to brave more than their just share of the dangers. PHILADELPHIA MEDICAL COLLEGES AND THE WAR. The medical schools of Philadelphia are to the front in patriotism. A relief corps or hospital corps consisting of a staff of five physicians and eight trained nurses will be organized with Dr. Martin H. Williams, of Jefferson Medical College, as chief, and will offer their services to the government. The staff of the Medico-Chirurgical College has decided to offer the services of the staff and the beds free of charge to the wounded soldiers. The University of Pennsylvania is most enthusiastic, and through the management of one of its students (Mr. Woodruff), the school, with the assistance of other schools, will probably offer two regiments to the national guards. Many of the students of the medical schools of Chicago have enlisted and great enthusiasm is everywhere manifest. WOMEN PHYSICIANS. This country is surely the Mecca of the woman doctor. Here they thrive and are an acknowledged factor in the medical profession. In 1870 there were 527 women doctors in America; now there are 4,500. Nearly all the specialties of medicine are represented in their number. It is without doubt that in every town of 10,000 or more inhabitants, one or more women can find a field for practice; and indeed it would seem that the harvest is ready and waiting for them, inasmuch as many women not only prefer, but demand their services merely because of their prejudice and assumed modesty. AMBULANCE SHIP. The purchase of the Cromwell liner, Creole, by the naval authorities and its conversions into a hospital ship is an original pro.vision first suggested by Dr. Van Riper, who outlines the following plan: The vessel as designed will be 3,550 tons displacement; 275 feet on the load line, and 300 feet over all; 50 feet beam and drawing 18 feet; a coal capacity of 450 tons, giving 18 days steaming at 10 knots. The water tanks will hold 9,000 gallons. The ship will carry 4 steam launches and 4 barges, each barge arranged with a flying floor between the thwarts so as to conveniently carry tackle coils on the floor. There will be beds for 274 and hammock space for 86. State rooms for 8 disabled officers, and cot space for 12. The forward wards on the upper deck have one tier of baths for a ward of isolation, or to accommodate more serious cases. The vessel can accommodate 336 wounded men. There are quarters for 4 medical officers, 2 apothecaries and 12 nurses. Near the center of the ship, on the bath deck, is a well ventilated and well lighted operating room, 18x21 feet. As soon as the action is over a launch will tow its barge alongside, receive the wounded and take them to the ambulance ship. Had the Manila battle been fought at sea such provisions would have been indispensable to the care of the wounded. AMERICAN MEDICAL ASSOCIATION.The annual convention of the American Medical Association will be held, beginning June 7, at Denver. The Western Passenger Association has granted a rate to Denver and return of one-half fare plus $2, with a thirty day limit. Tickets will be on sale June 2nd, 4th and 5th east of the Missouri river, and on the 5th and 6th west of the Missouri river. Application for similar rates has been made to all other passenger associations and to railroads not controlled by them and visitors to the meeting doubtless will be able to select any route and have the advantage of the special rate. Provision is being made by roads reaching the picturesque sections of the west and northwest for enjoyable trips of such length as may suit the convenience of the visitors and reaching as far as Salt Lake City and Yellowstone Park. To many this opportunity to view the scenic magnificence of our western country will be an exceptional one and the large number who will avail themselves of these excursions cannot fail in making them thoroughly pleasureable. *TREATMENT OF CHRONIC INTERSTITIAL NEPHRITIS. BY I. N. DANFORTH, A. M., M. D., DEAN OF AND PROFESSOR OF INTERNAL MEDICINE, AND OF CLINICAL MEDICINE IN NORTHWESTERN UNIVERSITY chronic interstitial nephritis has increased, It is obvious, however, that no general (a.) Abstinence from alcoholic beverages of all kinds. (b.) The selection of a dietary which throws the least possible strain upon the organs chiefly concerned in retrograde metamorphosis; in other words, the dietary most directly and easily respondent to combustion or oxidation. (c.) The continuous and persistent employment of tonic and alterative remedies; or remedies which have haemogenetic power along with remedies which have alterative or metabolic power. (a.) The first of these propositions needs neither demonstration or argument. It has already passed into an axiom. Every experienced clinician knows only too well how frequently alcoholic beverages are justly charged with inciting interstitial nephritis. And this is especially true of those patients who are "moderate" but habitual drinkers; whose kidneys are constantly engaged in eliminating alcohol, and are therefore constantly suffering alcoholic irritation. The dangers to the kidneys are far greater in moderate but habitual drinkers than in those who go on periodical "sprees" followed by seasons of total abstinence and a gush of temperance oratory. After the kidney has once entered upon the changes which constitute cirrhosis, it is doubly sensitive to alcoholic irritation. It should therefore be an inflexible rule that all alcoholic beverages be dropped entirely and permanently. It is almost as important that those noxious and filthy compounds, such as "root beer," "birch *Read before the Association of American Physicians at its meeting in Washington, May, 1898. beer," "ginger ale," and the whole category of so-called "temperance drinks," which are now so commonly found in the homes of the most exemplary people, should be rigidly excluded from the list of beverages of patients having contracted kidneys. (b.) The question of diet in cases of interstitial nephritis is still a questio vexata, and is likely to remain so until we have more successfully explored the hazy field of gastro-hepatico-intestinal dynamics. But it' seems to be unquestionable that a highly nitrogenous diet is positively injurious in all renal lesions, and the reason for this result seems definitely settled, namely, the fact that a nitrogenous diet is uniformly followed by the accumulation of lithic acid in the blood and tissues, and the consequent phenomena characteristic of "lithaemia." In clinical experience we commonly find that cirrhosis of the kidneys is accompanied by some degree of hepatic cirrhosis, and that the functional capacity of the liver suffers accordingly. It seems to be a well settled postulate of physiology that the liver more than any other organ, is concerned in converting insoluble uric acid into soluble urea. The healthy kidney readily seizes upon and eliminates urea; the contracting kidney surrenders this power reluctantly and slowly; the healthy kidney cannot eliminate uric acid with comfort or facility, and its presence is always unwelcome to the renal cells, while the contracting kidney is seriously irritated and injured by its presence. It is therefore of great practical importance that the dietary be selected with the view of reducing the output of uric acid to the minimum And that question must be settled by the practitioner, not according to any arbitrary rules-even though they seem to be sanctioned by physiological laws, and clinched by that delusive phantom called "experience" but by the results attained in each individual case. One patient can be confined pretty closely to a diet of milk and fruits, without suffering gastric torments, and an aggravation of renal symptoms; he can oxidize milk freely and rapidly; hence milk is the ideal diet for him so long, and only so long, as these conditions remain. The very next patient may revolt at a milk diet; it may cause gastro-intestinal mutiny, and if so it is all but sure to be fol As our knowledge of the natural history of lowed by increased albuminuria, uric acid and casts, and the nervous phenomena of lithaemia. But he can take a meat and vegetable diet with both comfort as regards digestion, and profit as regards the renal indications. Plainly, a nitrogenous diet is the proper regimen for him, in spite of the fact that he is committing physiological heterodoxy. But a question of very great practical importance is how shall the physician decide what is the proper diet in the individual case? The answer is not by any means difficult. It is obtained chiefly through the agency of the test tube and the ureometer. A decreasing ratio of urea, and increasing percentage of albumen, together with the coincident presence of the symptoms of uric acid toxaemia, should determine a change of diet, whatever it may be. This rule is a much safer one than any arbitrary dictum, based upon observations made in cases other than the one in hand. At the bedside in private practice, and especially in hospital practice, we are too apt to forget that every patient has his own peculiar digestive apparatus which will manifest its own individuality in contempt of the most highly scientific deductions, or the most carefully prepared diet-lists. Another practical point must not be forgotten: change of diet-variety is quite as essential to the renal invalid, as it is to a healthy person. When it was written "man shall not live by bread alone," the term "bread" was used in a generic sense, and included milk and meat as well. When the patient wearies of his prescribed diet the digestion fails and assimilation becomes faulty; then elimination is interrupted and auto-intoxication follows as an inevitable result. It does not matter so much what the particular form of diet is in interstitial nephritis, provided it be acceptable to the digestive apparatus of the patient to whom it is given; provided the quantity be not too great for the actual demands of the patient, so that there shall remain an unused overplus to be converted into lithic acid or its congeners, by imperfect combustion. The question of diet for a renal invalid is one of an individual nature, not to be settled by an appeal to laws physiological, pathological or chemical, but rather by the findings of the test tube and the ureometer, corrected and verified by the complex of coincident symptoms. While it is true that milk is an ideal diet in renal diseases, it is also true that every now and then we stumble upon a patient with contracting kidneys, who does best upon a flesh diet in spite of all our rules. I am accustomed to allowing fruits of all kinds; in fact, I advise their free and habitual use. The fruit acids do not disturb digestion, while they do gently stimulate and encourage the faltering liver and kidneys. It is also very essential that patients with interstitial nephritis be encouraged-in fact required to drink freely of pure water. It is just on this point that I experience my greatest difficulty. It is almost impossible to get patients to ingest habitually a proper amount of water. They will manfully swallow drugs ad nauseum, but they revolt at the idea of drinking four or five glasses of pure water a day. Hence, because I deem it very essential that the kidneys be "flushed" with water daily, I am obliged to resort to various harmless "remedies," to be dissolved in a full glass of water and taken on an empty stomach four or five times a day for the purpose of accomplishing the object in view. The waters of the various "lithium" springs serve a good purpose in this regard, since they at least possess the negative virtue of containing nothing harmful. (c.) Have Medicines, per se., any value in Interstitial Nephritis? Answering this question for myself, I have to say, first, that no remedies within my present knowledge will radically cure interstitial nephritis; in other words, the damage once done can never be removed or repaired by any means within our present reach; secondly, a proper treatment, persistently pursued, in an uncomplicated case, will frequently arrest the progress of the cirrhotic process, and prolong the patient's life, even to the allotted age of man. According to my way of thinking, there are three objects to be kept in view in addressing treatment to a case of interstitial nephritis: (a.) The persistent use of alterative remedies. (b.) The use of hæmogenetics or tonics when they are clearly indicated. (c.) The care of the heart. (a.) The alterative remedies to which I attach most value are mercury and iodine, with a growing tendency in favor of gold, also. Up to the present time, however, my preference is for mercury, persistently administered in minute doses three or four times a day. Of the mercuric salts, calomel, in doses of a tenth to a quarter of a grain three or four times a day is my first choice. My intention is to so graduate the dose as to exert a barely perceptible effect upon the bowels, and generally the smaller dose mentioned will be sufficient. It should be administered persistently, not less than three |