The spasms are a source of a great deal of discomfort and distress to her.

Apart from these spastic phenomena, the patient presents no symptoms on the part of the nervous system. There is no paralysis, the pupils, knee jerks and Achilles tendon reflexes are normal, and there are no symptoms on the part of the cranial nerves. The plantar reflex is nor mal on the left side, but on the right the spastic phenomena in the toes make a satisfactory examination impossible.

In diagnosis the question of hysteria scarcely arises. The absence of all of its stigmata-anesthesia, narrowing of the field of vision, etc.-and of all hysterical symptoms, as well as the fact that the spasms keep on in sleep as well as in the

waking hours, and the unchanged clinical picture for twenty years, preclude this.

Post-hemiplegic spastic phenomena, such as athetosis and chorea, have been attributed to lesions of the thalamus, supposed to be the site of higher reflex actions, and we can most easily explain the symptoms in this case by such a lesion. This would account for the transient hemiplegia, for none of the pyramidal tract fibres need to have been destroyed. The "crossed eyes" and double vision are not so easily explained. Possibly the history given is not correct, or there may, at the time, have been more than one lesion.

Discussed by Drs. Langdon, Kramer, Hoppe, Kendig and Zenner.

SODIUM CITRATE IN INFANT FEEDING.

Cotton,' in a recent article, has called attention to a number of assumptions prevailing as regards exact percentage in infant feeding, assumptions which are for the most part not borne out by facts. These are:

"1. The qualitative similarity in breast. and cow's milk of the lactose, fats, albu. minoids, proteids, and their chemical combinations with the milk salts.

"2. The claimed alkalinity of breast milk in contradistinction to the acidity of cow's milk.

"3. The possibility of a synthetical substitute for breast milk from cow products alone.

"4. The claim that cereals were not allowable because indigestible in the infant's secretions, and that they induced dyspepsia and intoxication by acting as decomposing foreign matter.

"5. The cereal gruels were no more efficient in the prevention of dense milk coagula than dilution with plain water.

I Journal American Medical Association, October 6, 1906.

"6. The HCl played no part in the digestive process until later infancy.

7. That the important proteid content of the baby's food could be made up from the non-coagulable whey albumin of cow's milk."

He believes that "the tendency in general is too much along the line of refinement of mathematical formulæ, the neglect of the obvious importance of gastric development along normal physiological lines." Recent work in infant digestion has shown that they can digest no inconsiderable amount of starch, and thus, as has been stated many times before, the most difficult of the artificial foods the young child is called upon to attack are the proteids of cow's milk; particularly is this true of the casein of cow's milk, and many plans have been tried to circumvent this. Of these plans, the dilution of the milk, to lessen the proportion of casein, followed by the addition of cream, milk sugar and other substances, has been and is the most popular. While the method itself is a rational and good one, it is too

complex for ordinary bed-side work. The difference in the milk supply from day to day, the difference in the proportion and richness of the cream, and the great liability of contamination of the latter with bacteria, owing to the faulty methods by which it is obtained, obviates itself otherwise very material advantages. In addition, it has not been sufficiently recognized that in diminishing the amount of casein the child has been deprived of a very important essential in its diet. Those who have recognized this fact have endeavored to lessen the indigestibility of the casein, if such a term may be permitted, by the addition of various salts, the most recent and valuable of which is the citrate of sodium. Many articles and reports of value of this substance have appeared in the medical journals during the last two years. The advantage of the salt is three-fold: It seems to possess the power of preventing dense coagulation of cow's milk in the presence of acid and the milk-curdling ferment (hence renders it easier of digestion); does not lessen the amount of casein (hence helps to preserve the child's nutrition); and lastly, can be carried out by the poor and ignorant, among whom elaborate percentage feeding is impossible. The process is exceedingly simple. Cotton recommends an aqueous solution of the salt containing from one to five grains to the drachm, and this is added to the milk just prior to the feeding in the proportion of one, two or three grains to the ounce of milk. Lime water and sodium bicarbonate are not used. Cotton says, as a result of his experiments, "the coagula of citrated milk are softer, smoother, and more jelly-like, or more flocculent, than those of milk not treated."

KEEP THE streets CLEAN. Physicians will, in 1907, watch with interest the actual working out of the movements planned during the previous

year and just now being placed in operation. ation. The most interesting of these, from a purely medical standpoint, is the medical inspection of schools and schoolchildren which was discussed in these columns last week. As has been said before, the success or failure of this movement rests mainly in the tact and discrimination of the inspectors themselves.

Another movement of certainly as much commercial and economic interest as medical is that taken in an endeavor to stop,or at least lessen, what has been called the smoke nuisance. The work of the Smoke Abatement League, mainly through the enthusiasm of its distinguished president, has borne good fruit. The League have acted wisely, with perseverance and energy, have demonstrated even to the Gas Company that they are not to be "bluffed." The year 1907 sees, at the latter company's generating station on the Canal, two thin filmy clouds of smoke issuing from the chimneys, where less than a few weeks ago twin dense columns of filth were belching forth, covering everything for squares around with a heavy layer of soot. And dozens of such cases might be instanced. Dr. Reed estimated that 30 per cent. of the waste was eliminated last year, and this figure will be greatly increased in 1907. It would be well for the corporations that are still defiant to remember that the League is acting well within its legal rights and can compel obedience. A number of suits will be fought out in the courts this year.

To the medical man the thought naturally arises that if pure sterilized carbon is recognized as a menace to a community, how much more unhealthy is the filth with which our streets are literally filled-filth loaded with pathogenic germs which, when dried, carries these organisms to the human in the form of dust. It has been preached for years that some of the most prevalent and fatal of the infectious

diseases are transferred from one individual to another by this means, and yet little effort and that spasmodic at the best-is made to remedy the evil. Whether the gentleman whose duty it is to see that the streets are kept clean is handicapped, as he claims, or whether he is merely incompetent, is not a matter that greatly concerns the citizens. The fact remains that the so-called Street Cleaning Department is a farce, and if the powers that be are not satisfied with the work of the man who thinks he can keep the streets of Cincinnati clean by observing how they do it on the other side, they had better employ some one who can deliver the goods. If they are satisfied, then his claim of inadequate working-force seems justified, and the board had better furnish the help needed. After observing the comparative cleanliness of the streets in foreign cities and in other cities of this country, one becomes very much ashamed of his native Cincinnati. Instead of wasting time and breath discussing park systems, boulevards, viaducts, and other far-fetched schemes for advertisement and beautification, it might not be out of the way for the business clubs to do a little agitating in the line of keeping the streets in a condition of at least semi-cleanliness. Those other schemes will keep, but it seems to us that the best advertising that a city can have is a reputation for cleanliness in its public thoroughfares. It is certainly conducive to the health of its citizens, and that is a consummation devoutly to be wished.

Laboratory Report.

6.

7 ....17

Diphtheria.-Original: 2 positive, 16 negative. Discharges: o positive, 11 negative. Total examinations, 29.

Sputum 13: 5 positive, 8 negative.
Widal 16: 12 positive, 4 negative.

There were 136 deaths reported during the week, 12 less than for the corresponding week in 1905. If the average number of daily deaths continues for the next three days there will have occurred during the year 7,139 deaths. Estimating our population at 380,000, this gives us a death rate of 18.78 per thousand.

Physicians have been urged to send in all births before the close of the year. The expected response to this request has not occurred, but 59 births being sent in during the week. While the number of births recorded for the year will greatly exceed the number reported during the last few years, yet it will probably fall behind the number reported as long ago as 1891.

Diphtheria.-Thirteen cases were reported, 5 less than for the preceding week, and 2 less than for the corresponding week in 1905. During the year there has been reported 673 cases with 80 deaths.

Scarlet Fever -Seven cases were reported, an increase of 3 over the preceding week, and 14 less than for the corresponding week in 1905. During the year 169 cases have been reported, with 8 deaths.

Typhoid Fever.-Thirty-eight cases were reported during the week, 10 less than for the preceding. There were 5 deaths. During the year, 1,924 cases have been reported, with 235 deaths.

Measles.-But 5 cases were reported. During the year there have been reported 2,698 cases. Fifty-eight deaths attributed directly to this dis ease occurred. On 67 death certificates measles was given as a contributory cause; there were, therefore, 125 deaths due to measles or its sequelæ.

Smallpox.-There were no cases of this disease. We have had but 2 or 3 cases during the last 6 months. Since January 1, 1906, 162 cases with I death were treated at the Branch Annex.

Chicken Pox in an adult is looked upon with suspicion by the Department, and the Medical Inspector examines all cases reported as such. Please, therefore, be careful in reporting chickenpox to give the age of the patient.

Phthisis Pulmonalis.-During the year 885 deaths have been caused by this disease, 12.39 per cent. of the deaths from all other causes.

The Department is sending with this bulletin a leaflet explaining the new system of School and Medical Inspection to be started January 1, 1907. Physicians are most earnestly requested to cooperate with us, and to overlook such defects as are bound to become manifest. Complaints and suggestions will be given very careful attention. The contagious disease inspection will at first be limited to diphtheria and scarlet fever.

Laboratory Report.

Fifty-eight examinations were made, 9 less than for the preceding week. Sixteen Widal tests were made, 12 positive and 4 negative.

Milk Examinations.-Eleven samples were examined, of which 4 were of wagons and 7 store samples. One sample (store) was found to be deficient in fat and is being prepared for prosecution. Seventeen wagon and 137 store, making a total of 154, inspections were made. Very respectfully,

SAMUEL E. ALLEN, M.D.,
Health Officer.

The Treatment of Sciatica. [The prize offered by the New York Medical Journal for the best essay on this subject was awarded to Dr. E. S. McKee, of Cincinnati. The article appears in full below.]

The first essential to the successful cure of sciatica, the hip gout of Pliny, is a thorough knowledge of the individual patient in hand. We should in the beginning institute a most exhaustive physical examination, not only of the sciatic nerve, but also of the entire nervous system, and the patient's whole body, family history, diseases, mode and place of living, business, habits of life, and diet. If the patient is a woman, especial attention should be given to a careful rectal and vaginal examination, for the disease in women is often due to pelvic tumors. One cannot know too much about his patient suffering from this obscure malady.

Treatment should commence with that best of all starters, a mercurial purge, fol

WM. MUHLBERG, M.D. H. W. BETTMANN, M.D.

lowed by salines. Constitutional elimination and general therapeutical measures to relieve pain and promote sleep should be the treatment instituted as soon as the diagnosis is positively settled and the causative relations made clear. Morphine should be used with extreme caution, owing to the very great danger in these cases of forming the habit. Rheumatic cases are generally benefited by the salicylates, syphilitic cases by the iodides, and gouty cases by colchicum and the salines. One of the best combinations of drugs in the acute stage is the following, which should be preceded by the calomel and the salines :

Aspirini (acetyl salicylic acid),

dr. i, or 4.00 grammes Phenacetini (acetphenetidin),

gr. or 3.33 grammes Quininæ sylicylatis, gr. xx, or 1.33 grammes Codeinæ sulphatis, gr. iiss to v, or

0.15 to 0.33 grammes M. Fiant capsule No. x. S. Take one every two or three hours.

Injection Treatment.-Hypodermics of very large doses of strychnine in the re

gion of the painful parts have cured cases which were rebellious to every other plan of treatment. Injections into the region of the nerve of atropine sulphate, gr. 1/150, three times a day, also cocaine injections as near the nerve as possible, are frequently followed by success. Deep injections of alcohol, cocaine and alcohol, stovaine (amylene hydrochloride), So per cent. alcohol and the incorporation of o or of cocaine or amylene hydrochloride. Relief is obtained in about 90 per cent. in from two to four injections. Relapses, generally after the fourth or fifth month, occur in about one-third of the cases, but yield readily after one or two injections. Betaeucaine (benzoylvinyldiacetonealkamine), 6 per cent. solution in 0.8 per cent. salt solution, should be injected in the region of the sciatic notch. When a large wheal appears under the skin the needle is pushed down till a jerking shows that a nerve has been touched, then 70 to 100 c.c. are rapidly injected. Functional and complete relief is almost instantaneous. In a portion of cases only is a second injection necessary for complete cure. The hypodermic injection of sterilized air is sometimes quite beneficial, and should be conducted as follows: After sterilizing the region where the injection is to be made a sterilized hypodermic needle is inserted under the skin, and as soon as one is sure that no blood-vessel has been punctured, a rubber tube is joined on to the needle and air from a rubber bag is injected by simple compression. To be quite safe, it is well to place a glass tube containing a little cotton between the needle and the bag. The injection should be stopped when the patient no longer complains of pain. A slight amount of massage should be used every day till crepitation disappears.

The rest cure of Weir Mitchell is bene

ficial in some cases, and the fixation of the limb in plaster of paris is good treatment, especially in those cases where the vocation necessitates violent exercise of the lower extremities. Change of occupation is often necessary to the active, or vice versa. The sedentary person should sit on a soft cushion to protect the nerve from pressure or injury.

Massage along the course of the nerve, even though painful, is often of benefit in relieving adhesions. In true neuritis massage is, as a rule, not beneficial. Massage,

or better, mechanical vibration, is of value in the chronic stages where atrophy has commenced.

Hydrotherapy, judiciously administered, should always be accorded consideration. It has many cures to its credit. The wet pack administered at night is a very excellent means of relieving pain, as well as for influencing, favorably, the neurotic process. For this purpose we may use the leg of a heavy pair of drawers dipped in water at 65° F. and placed in position like a stocking. A roller bandage is then applied so that the leg may be kept in perspiration all night. This is removed in the morning and followed by a warm water ablution and massage. Ten or twelve packs usually result in much improvement. The half combined bath in the subacute stage proves quite serviceable. Patient sits in a vapor bath, which comes up to the waist line only. This, while it does not exhaust the patient as much as the full vapor bath, allows a much higher temperature to be borne by the affected part; 110° can be tolerated for from ten to fifteen minutes. At the end of this time the patient sits in a bath heated to a temperature of 95° F. for eight minutes, and during the last three minutes a hot undercurrent douche at 102° to 112° F. is applied to the affected limb. The combined bath alternated with the natural swimming bath is of value. The internal bath by the ingestion of large quantities of water is advisable.

Electricity. The galvanic current should be applied to the nerve from four to eight minutes, and should not exceed from three to five milliamperes. When the nerve substance has been involved gentle muscular stimulation with the uninterrupted galvanic current keeps the structures in good condition and prevents atrophy. The static spray (positive) locally is good. The apparent anodyne action of faradism in sciatica is due to its alterant action on the muscular tissue, and through the latter on the circulation. The blood supply is regenerated and the cry of the nerve for healthy blood is stilled. Painful applications of the faradic current are not proper.

Surgical Treatment.-In cases of long standing it is advisable to make an exploratory incision to expose the nerve trunk, incise its sheath, and free it from surrounding adhesions. Some good re