to record his temperature twice daily for the next week, and at once to notify me of any abnormal change in this or other respects. During this first week of his illness repeated examinations were, with the exception of the above symptoms, entirely negative, and while the chill, headache, myalgia and fever pointed to some mild infection no indication of its source or nature was then discovered. In view of his later history this fact seems worthy of emphasis. On the 9th day following his discharge, having meanwhile regained his usual health, a slight stiffness of the neck, with discomfort on swallowing was complained of, and, towards night he had another well-marked chill shortly after which I saw him. The temperature was then 103° and the pulse 112, regular but unexpectedly small. On examination the mucous membrane of the nose, mouth, and pharynx was found normal, and the teeth, gums and tonsils in good condition, nor was there any ear-ache or mastoid tenderness. On the right side the submaxillary glands were enlarged and tender on deep pressure, and diffused swelling was noted, most prominent behind and below the angle of the jaw, involving the cheek and neck anterior to the sternomastoid. Next morning the swelling had increased, and the tissues over and above its center, though not distinctly edematous, felt boggy and inelastic. The upper half of the sternomastoid was painful on pressure. I might say that for some time past "mumps" had been epidemic in the neighborhood, and as one member of the family was at that time down with it, the boy's condition had at first suggested that complaint. My next visit, a few hours later, convinced me, however, that such was not the case, and that evening Dr Hoover kindly saw him with me in consultation, when the diagnosis of thrombosis of the right internal jugular vein was made. On this occasion a careful general examination failed, as before, to find any local lesion. In the course of the vessel named a well defined and 1esistant enlargement could be felt, of the diameter of a lead pencil, and an inch or more in length. Above it was lost under the ramus of the jaw and below it ended abruptly at the spot where that vessel crosses the sternomastoid muscle. Tenderness was marked along its course. The dangers of septic thrombosis in such a situation are too obvious to need description. His parents, who are fortunately of exceptional intelligence in medical affairs, were fully advised of the nature of the case and the more essential points of treatment. During the next two weeks, pending absorption of the clot, the boy's condition was decidedly critical. Appetite quickly failed, the tongue became brown and dry, and the frequent atypical variations in both pulse and temperature, along with other symptoms, showed a well-marked sepsis. For the first week his general state varied but little, and the thrombus showed no decrease in size though the general swelling had rapidly subsided. On the eighth day, however, a sudden collapse set in which, but for prolonged and heroic stimulation would, I believe, have proved fatal. His temperature, after a sudden fall to 96°, ran up in an hour and a half to 105°, the pulse became thready and totally arhythmic, and his respiration rapid, jerky, and very shallow. Whether this was a mere acute exacerbation of the existing sepsis or due to slight cardiac or pulmonary embolism, I cannot say. Under large doses of strychnin, ammonia, and spartein, with enemata of whisky and hot, black coffee the symptoms subsided, and by night his state was satisfactory. Next morning the clot was distinctly smaller, and from that time resolution proceeded steadily. A week later nothing but a slight thickening of the vessel-wall remained. Cleveland Journal of Medicine THE OFFICIAL JOURNAL OF THE CLEVELAND MEDICAL SOCIETY AND OF THE UNION MEDICAL ASSOCIATION OF NORTHEASTERN OHIO PUBLISHED THE TENTH OF EVERY MONTH AT 512-515 NEW ENGLAND BUILDING One Dollar a Year in Advance Single Copies Ten Cents F EDITORIAL RENAL INSUFFICIENCY AILURE of the kidneys to properly perform their functions, as evidenced by the secretion of scanty high-colored urine is a condition frequently met with by physicians and is usually ascribed to and treated as a precocious stage of fibroid kidney. There is no question that this view is very often the correct one, probably always so as to the prognosis, if the condition is not properly treated. There is a factor in its etiology, however, that is frequently found if sought for, but which is fairly constantly overlooked by physicians. Huchard says that even when there is no albuminuria, renal insufficiency is an almost constant symptom of myocarditis, yet the heart is seldom examined in such cases and the profession fails to realize that the concentrated, scanty urine being due to a weakly acting heartmuscle, our therapy can best be directed towards the heart. It is not forgotten that chronic myocarditis is in most cases associated with more or less general arteriosclerosis, this indeed being the reason why renal insufficiency appears so often as a premonitory sign of interstitial nephritis, connectivetissue hypertrophy in the kidney being prone to proceed pari passu with the same change in the arteries. If renal insufficiency occurs along with obesity, which is nearly always associated with arteriosclerosis (Whittaker), the heart of such a case should be carefully examined and closely watched. Indeed in all cases of renal insufficiency the physician should look for the signs and symptoms of myocarditis. Weakness of the heart, the first sound being muffled in character, with irritability of action, feeble apex-beat, arhythmia, palpitation and a sense of distress in the pericardium are among the commoner signs. Intercostal neuralgia, pulse marked by irregularity, inequality, and at times the galop-rhythm, and in later stages dyspnea, vertigo, stasis in the lungs and dilatation of the heart will make the diagnosis not difficult. The gouty diathesis, inherited and acquired, and marked neurasthenia are frequently found in these cases. In the treatment of these cases fresh air and graduated exercise are of the very first importance. Change of climate and hydrotherapy are indicated in suitable cases. Regularly administered and fairly large quantities of pure water, either hot or cold, are of great benefit. Among drugs, quinin in tonic doses is the most useful, while strychnin in small doses and digitalis used intermittently will be found to be beneficial. If there is very great arhythmia sulphate of spartein in grain doses is of the highest value. It needs hardly to be stated that constipation calls for cascara and excessively acid urine the temporary use of alkalis. T SUPRARENAL CAPSULE AS AN ASTRINGENT HE intense and lasting astringent effect of the extract of Suprarenal Capsule when applied to mucous surfaces gives this agent an unique value in a certain class of affections. Of its action on the human economy when ingested or given hypodermically, little is definitely known. The adult organ consists of a cortex and medulla, the extracts of which have very different physiologic effects. That from the medullary portion, at least from the sheep and hog, seems peculiarly fatal to mammals when introduced directly into the circulation, while the cortical extract is practically inert. The preparation usually supplied to the trade in the form of a saccharated extract, is best used in aqueous solution. When applied in a strength of from 2 to 4 percent a remarkable astringent action is observed. The membrane, whether normal or patho'ogically congested, becomes suddenly pale, remaining so from one to two hours. This ischemia is far more marked than that obtained from any other agency. When used on the conjuctiva this effect takes place without smarting or irritation, nor is any secondary congestion observed. On the nose and throat the effect is similar. As an adjuvant to cocain, in preparing the membrane for operation or in the treatment or chronic relaxation, it has proved of the highest value. So intense and lasting is its action that, as one observer expresses it, it is possible with an applicator moistened in the solution to write upon the mucous membrane in white letters. This of course represents the area of its astringent action. It will be of interest to know whether its repeated application may be able to overcome the chronic hypertrophies which at present are so often subjected to operation. From reports of its action on other organs it may be inferred that its use, perhaps in sup pository form, may prove of value in cases of hemorhoids and relaxation of the rectal membrane. Indeed, it would seem that, though of limited use, it is likely to prove, when indicated, a peculiarly valuable addition to the materia medica. THE ARMY DIFFICULTIES HE Court of Enquiry ought to be able to fix a good part of the responsibility for abuses in the late war without much trouble. Dr. Bunts' very interesting talk before the County Medical Society, October 6 shows clearly where a part of the fault lies. The hospital fund, as it appears, is raised by the issuing by the Commissary department of an equivalent in money for the rations of the sick men. Barring that, the surgeon must himself turn the supplies into money. Dr Bunts says: "The volunteers were ignorant at first how to get supplies for the sick and for the first week or two I paid for the supplies out of my own pocket as I didn't know how to get them any other way. It seemed to me the regulations were lived up to when convenient and not when inconvenient. When I learned the regulations I applied to the commissary to have them transferred into money for the hospital, but he absolutely refused to do it, saying that he had bigger things to attend to. I had ten or fifteen sick men to look after at the time and I didn't get a cent in return from the government for what I had expended. In fact, I didn't ask it." The commissary who absolutely refused to do his obvious duty to those sick men should have been strung up by the thumbs until in a better frame of mind. It would be hard to conceive, however, a more brutal or unnecessary red tape than that requiring a surgeon to either go out and peddle supplies to get milk for his hospital patients or leaving him to the mercies of an overworked and usually inefficient commissary officer. Apropos of the commissary department, the Philadelphia Medical Journal has listed a large number of officers of that branch of the government service who come of powerful families and who were evidently appointed for purely political ends. These men were parasites instead of providers and the army fell a prey to them. It is probably true as Napoleon said, that an army moves on its belly. Our army apparently moved on an empty one. C A DISHONORABLE DRUG-HOUSE COMPETITION among drug manufacturers has become so keen that criminal methods are being resorted to by some in the hope of stealing success. A most flagrant instance of this which has lately come to light is the case of an eastern manufacturer who has been using, as an advertisement in the medical press, a laudatory mention of a certain preparation by a State Board of Health, but in which he has deliberately inserted his own name in place of the name of another well-known and highly respected firm whose name had been published there by the makers of the report. The case is becoming well known to the profession and as the evidence of the forgery is perfectly clear and is made up of sworn statements, it is certain that the offenders will suffer that loss of prestige which must follow the employment of underhand methods. It is perfectly clear that a firm which will forge a name will also resort to the use of unreliable drugs and dishonest methods of manufacture. This is so self-evident that it is the more remarkable that any firm should risk its whole business and reputation in so discreditable and dangerous a venture. Such an instance as this is very unpleasant to contemplate but the profession should be informed in regard to it, because upon the honesty of the great drug manufacturers rest the safety of our patients and the maintenance of our reputation. CHRONIC HEADACHE NE of the most powerful drugs for the prevention of sick and nervous headaches is water. The result of the drinking of large quantities of water daily in cases of life-long addiction to the headache habit is little short of marvelous. This simple prescription is one of the hardest to induce patients to take in sufficient quantities. Water must be disguised, sneaked into the patients' dietary by stealth. It must be diluted by lithium salts, flavored with strychnin, taken because it wells up out of the ground "magnetized," taken for any except the real reason, that it is water. The medieval prejudice against water was somewhat well-founded, as nothing was then known of the good effect of boiling water, or of the necessity of obtaining pure water away from sources of pollution. There was a natural impression that water taken undiluted and in all its virulence was very deadly. Its mode of preventing headache is not quite a simple one. It flushes out the poisonous accumlations of constipation, washes away toxins and germs of diarrhea, raises the blood pressure by diluting and carrying off through the kidneys the irritants which contract the arterioles, and cuts short rheumatism in the same way. In one or all of these ways it may prevent several kinds of headache. The most common contraindication of water given by the stomach is motor inefficiency of that organ with or without dilatation; its occasional failure should lead one to look for such a lesion. W HYDROPHOBIA AND BOOK-REVIEWS E wish to call especial attention to two letters contained in this number. The one on the sad death from hydrophobia of Dr Todd of Toledo suggests, at first, the reality of the disease called hydrophobia. On second thought, the rabbits' inoculated by Dr Ohlmacher died of the paralytic form of rabies, said by scoffers to be a laboratory form of |