vates acute conditions. Senega is a drug that has largely gone out because it was wrongly used.

Aconite and Veratrum

These drugs were formerly well used, and some practitioners employ them properly today, never giving for over forty-eight hours and always in small dosage in sthenic conditions, never in asthenic ones. The use of the alkaloids derived from these drugs is never, in the opinion of the present writer, justified in internal medicine, and the misuse of these alkaloids brought two exceedingly useful drugs into disrepute. These drugs were wrecked by the alkaloidal craze but should come back into favor again.

Lobelia

There is no doubt whatever of the activity of lobelia. Consult any text-book. There are plenty of rational uses for lobelia; yet it has largely gone out of use because its advocates were erratic and Of recent years it extreme in their claims for it. was even urged as a sure thing for diphtheria, given hypodermatically or intravenously, while antitoxin was held up to ridicule by the lobelia cranks. This was pure folly and has caused discriminating physicians to abandon lobelia, which was and is a very useful drug. From the time of the Thompsonian craze lobelia has been the innocent cause of acrid discussion and all sorts of therapeutic nonsense.

Gelsemium

Here is a drug largely used in the South but which has never attained to any extensive vogue in the North, and its advocates have steadily maintained that its toxicity is almost negligible. It is probably less toxic in the southern fevers than in the northern uses thereof in diseases of the nervous system; but gelsemium is very toxic and has fallen into disuse because employed in excessive dosage. The drug is one of marked activity and great usefulness, especially in the treatment of certain nervous conditions. Doctor, read up gelsemium, both in Regular and Eclectic literature; then try it carefully, and you will be surprised at your former neglect of a fine remedy.

Pilocarpus

In a

Theoretically, this drug and its chief alkaloid fills many indications; it is assuredly very active and its very discreet use is often productive of much good; but, in general, it is too depressing. Here is a drug of known activity largely going out of use: doctors are afraid of it, and they use other and less depressing drugs to fill its indications. hospital ward, where the patient can be watched, pilocarpine is often of the greatest usefulness. The whole tendency is against the use of very depressing drugs, specially when they are, like pilocarpine, of little service except in dosage verging on the danger

Cannabis

This is another drug of great activity, but its preparations are notoriously unreliable and uncertain. When one is sure of his preparation, the drug is very useful within a narrow range. Consult the textbooks. Comment

Perhaps some of the ultra-modern physicians will consider this subject as unimportant. Not so! In this day of advanced pathology and diagnostics, remedies for ordinary ailments are unduly neglected. Remedies must not be neglected, and we must do all we can to bring into modern usefulness the comparatively few defined drugs we have, even those which meet minor indications and meet them well. Symptomatic medication is important, despite our advances, and we cannot afford to allow really useful drugs to be discarded.

But there is always a reason, and this editorial which uses a few drugs as illustrations is to emphasize the fact that our present neglect of drugs, or certain ones, may be founded on the following facts: first, a drug may be neglected for the just and sufficient reason that it is unnecessary, a comment applicable to many remedies long in use; second, the wrong proximate principle may be used and the mistake be readily corrected, either by employing the right proximate or the whole drug; third, the whole drug may be too nasty to use, whereas its active principle should be used and may be very useful; fourth, the drug may be used under entirely wrong indications, whereas when used properly the agent is most valuable; fifth, the drug may pass into the discard by reason of some modern craze or style that runs its course, leaving therapeutic wreckage and nihilism behind; sixth, erratic and extreme claims for a drug turn the profession against it, whereas conservative claims may establish a proper place for the drug; seventh, a toxic drug may be used in excessive dosage, thus bringing it into disrepute, whereas proper dosage may show the great value to clinical medicine of a toxic agent; eighth, a drug may be so depressing that physicians are justly afraid of it, and lastly, the pharmaceutical preparations of a drug may be unreliable and thus an intrinsically useful remedy be neglected.

Modifying Milk for Sick Adults

We

Renvall made a good suggestion that has worked out well in practice: he feeds diluted cream. have employed it by procuring a good double cream and whipping it up stiff, or procuring it already whipped from the nearest şoda fountain. With an ordinary rotating egg-beater very gradually add water, continuing the whipping actively during the process, until the mixture is one-fourth cream and three-fourths water, add a little salt, and feed cold or iced. Carbonated water may be used as a diluent. Remember that ordinary cream will not whip.

Another good plan is to prepare malted milk by adding the powder to fairly warm water and incorporating well; then add pure cream to the mixture, put on ice for an hour, and serve with a little grated nutmeg and a spurt or two from a siphon of carbonated water. Powdered milk may be used if malted milk does not agree. In both of these products the casein has been flaked or modified.

If a hot drink is desirable, we find a reversal of the usual coffee and cream mixture, viz., cream flavored with coffee, to work nicely. Use ordinary cream and heat it in a double boiler; add a little strong coffee, and serve.

Our Medical Schools Over-Manned

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N ARMY with too many officers and few privates is often played up in comic opera, but it actually exists in real life, much to the disadvantage of the army. Yet such a condition exists in our medical schools. Eliminating the nondescript schools. and those giving only the first two years of a medical course, there are 14,132 medical students enrolled in the schools of the United States, and 7589 professors, assistant professors, assistants, demonstrators, etc., to instruct these students, or 1.87 students to each teacher one teacher to less than two students. What a situation! It is pedagogically ridiculous and economically wasteful.

There is almost no parallel to this situation in schools giving instruction along other lines, but it is actually growing worse in the medical schools. No wonder that medical education is costing too much and that our courses are unbalanced, as all of these specialist professors insist on giving lectures, demonstrations, etc., filling the hours with predigested smattorings of a lot of inconsequentials and leaving insufficient time for things of greater weight and importance to the student.

This condition is largely due to a host of practitioners, few of whom are real teachers, crowding on to facilities to boost their own practices, and it is vastly unfair to the students. We have met three recent graduates lately who have just entered practice, and every one was studying therapeutics and materia medica, for they had suddenly discovered

they knew almost nothing of these subjects and vitally needed to know them. These students are angry at their professors for failing to teach them the things they need in order to make a living from practice. It is time for about five thousand professorial resignations.

Gastric Neuroses

Nervous dyspepsia is a very frequent complaint. It is characterized by both gastric and nervous symptoms. On the gastric side we have as prominent symptoms anorexia, nausea and vomiting, and gaseous and acid eructations. Among the nervous symptoms are general depression, dizziness and headache. There is a total absence of demonstrable anatomical lesions in the stomach, and a predominance of gastric and nervous symptoms as above. These cases are frequently classified under neurasthenia. Occasionally they may and do occur in connection with definite organic lesions. Reflexly, disturbances of the nervous system may result from gastric troubles.

Classifying the drugs for the nervous symptoms we have: (1) sedatives and anti-spasmodics, as valerian, the bromides, cannabis indicae and sumbul; (2) general tonics and stimulants, as strychnine and nux vomica; (3) narcotics and antineuralgics, as codein, opium, veronal and aspirin.

Certain disturbances of the stomach are secondary to nervous affections, notably the gastric crises in syphilis, the vomiting of meningitis and brain tumor, and the various psychoses. Then, too, irritants such as tobacco acting on the secretary nerves, also pylorospasm, chronic appendicitis and diseases of the gall-bladder and genitourinary tract not infrequently give rise to various gastric symptoms.

The neuroses are classified as (1) motor; (2) sensory; (3) secretory. For the sensory group sedatives, narcotics and antineuralgics are used. For the depressive group the stimulants are indicated. For the secretory and motor, the alkalies, HCl and the bitter stomachics.

Gastric lavage is also of use in prolonged pylorospasm with distension, and in the depressive and irritative conditions.

Hydrotherapy is of value in the form of hot water bag to the epigastrium, hot and cold water coil, ice bags, general baths as cold sponges in the morning, and sometimes a hot bath at night with a hot drink to induce sleep. Many needless abdominal sections are performed in these cases, hence a correct diagnosis is of paramount importance.

Pylorospasm may be due to a number of organic conditions as ulcer, erosion, carcinoma, etc. The chief symptoms are sudden shock, cramp-like pain in epigastrium with eructations and vomiting. The treatment consists in regulation of diet, change of scene,

if possible, gastric lavage, belladonna internally and hot applications.

In Hypochlorhydria there is a general diminution of all secretions. This also occurs in chronic gastritis and carcinoma of stomach. The treatment is dietetic, a carbohydrate diet, small feedings at frequent intervals, and dilute HCl, 10 to 20 minims in water.

Nervous vomiting occurs in young women, and the nervous symptoms are predominant. The vomiting may sometimes persist for months. The condition may be controlled by regulation of diet, building up patient, change of scene, mental and physical rest, and rectal or duodenal alimentation if necessary. For the gastric symptoms, sod. bicarbonate, gentian and gastric lavage, in addition to above. For the nervous symptoms, give sod. bromide, veronal at bed-time, and after two week's gentian before meals. Where the gastric symptoms predominate, we use Tr. cannab. Cerium ind. and valerian in place of bromides. oxalate and bismuth are useful for nausea.

It is the general treatment, physical and mental rest, and a thorough search for and removal of the cause, if possible, which are most important in this distressing condition.

Treatment of Tuberculosis in General

I

Hospitals

N 1916 the National Tuberculosis Association advocated the plan of opening tuberculosis wards in general hospitals, and at the 1921 meeting of the American Medical Association this plan was endorsed. There are at least two million tuberculous persons in the Union and it is possible to admit only a small proportion of them to special tuberculosis institutions. The help of the general hospital is needed. Not that we approve of the plan of herding large numbers of the tuberculous indiscriminately together, for we do not; but there are many cases needing hospitalization and that ought to have it near to their homes, not at some far distant point.

The public generally, as well as the incipient case of tuberculosis, have a horror of the special tuberculosis institution, and for this horror there is quite a little statistical basis, as well as some very human, even if mistaken, reasons. Furthermore, this plan would keep the family and the family physician in touch with the patient, which is a very desirable thing. The half-way house to this plan is the recently advocated county tuberculosis institution, a plan not yet proved out as regards efficiency.

We believe it is a mistake to shoo the general practitioner off the field of tuberculosis work; for, rather, the sensible thing to do, and the practical one as well, is to engage the interest and active aid of every capable physician in the fight against tuberculosis; it is too big a proposition to entrust wholly to the specialist or to special institutions.

COMING IN NEXT ISSUE

Surgery of the Thymus Gland, by Albert J. Ochsner, M.D., LL.D., and Frank H'Doubler, M.D., Ph.D.

The thymus belongs to the so-called group of glands of internal secretion, being particularly closely related to the thyroid. In cases of hyperplastic thymus which cannot be relieved by deep X-ray therapy, in the young or adult, thymectomy is indicated if there have been grave signs or symptoms of tracheal stenosis or if there is ground for fearing them.

The operation may be expected to accomplish several results: mechanical relief, decreased secretion and stimulation to subsequent normal tissue regeneration.

Ovarian Hemorrhage, not Due to New-Growths or Pregnancy-With Report of Two Cases, by J. L. Bubis, M.D., F.A.C.S.

Abdominal hemorrhage is a grave condition and requires serious and prompt attention. To know clearly where the bleeding is from, and consequently to know how to proceed, is always a pressing question-a question of life and death. Dr. Bubis differentiates ovarian hemorrhage from the usual entities it is often confused with. It goes without saying this short and practical paper is well worthy of consideration and should not be overlooked.

Unscientific Practice-Are You a "Pill Doctor?" by John U. Fauster, M.D.

Dr. Fauster says that while he has due respect for the responsible pharmaceutical producers, and realizes that the refinements in therapy are in a large measure their handiwork and that the development of the biologicals is an epoch which could be realized only with their co-operation, yet, on the other hand, the nostrum vender, whether he solicits patronage from the medical profession or from the laity, cannot be too strongly condemned.

Some Common Forms of Nasal Obstruction in the Adult, by L. F. Long, M.D.

Dr. Long says it should be remembered that a deviated septum does not call for operation unless ventilation and drainage are interfered with. Also it is important to carefully examine these cases and institute proper treatment, since nasal obstruction causes great discomfort and produces many diseased conditions.

Acromegalia-With the Report of a Case Having Lymphatic Leukemia, by Hyman I. Goldstein, M.D.

Few diseases are as puzzling as acromegalia is. For some obscure reason, the pituitary body "goes wrong," becomes disturbed, appears to overfunction, and the skeletal tissues, like wild weeds, begin to thicken, enlarge, grow and overgrow. Both body-anatomy and body physiology become perverted, controlless, helpless and hopeless. Dr. Goldstein's case of acromegalia, complicated by lymphatic leukemia, studied thoroughly and presented in detail, is illustrious, interesting and instructive. It is one of the diseases rarely met and the paper should attract unusual attention.

By D. ALEXIS MYERS, M.D., D.D.S. Professional Building, 1831 Chestnut Street, Philadelphia, Pa.

Assistant Oral Surgeon to Temple University Dental School, Philadelphia; late Syphilographer and Dermatologist to Walter Reed U. S. General Hospital, Washington, D. C.; late Derma

tologist, Camp Merritt, N. J.

Treatment Is Individual; Never Routine

In the treatment of syphilis the old saying aptly applies, that medicine is an art as well as a science. Laboratory findings must never, and cannot, usurp the results of clinical findings. Injections of this or that medicament are not to be regarded as all that is required, and all cases are not to be treated alike.-THE EDITORS.

T

HE COMMANDING importance and the appalling prevalence of syphilis can be best appreciated through a statistical consideration, as recorded through certain registration areas. In 1915, the number of deaths from syphilis in the United States was 5819. And yet we must, from every day experience, conclude that even these figures are far too low, for physicians hesitate to inscribe such a cause of mortality in filling out the death certificate. It would be interesting to know how many persons die annually in the United States from syphilis. Cases that are reported as due to general paresis of the insane, apoplexy, tabes dorsalis, and other medical entities, are too often the sequelæ of syphilitic infection.

It is the opinion of the Hibbs (Journal of Sociological Medicine*) that practically all deaths reported under "general paralysis" result from syphilis; but he is extremely doubtful whether such cases as congenital debility, icterus and scleroma are at

*An excellent resumé of Hibb's elaborate and painstaking study appears in The Urologic and Cutaneous Review, January, 1919.

all due to syphilis, although at times they are believed to be by some of the profession. He also emphasizes the fact that, estimating the prevalence of the disease as judged by morbidity statistics, two methods of diagnosis must be distinguished. The first is what may be called the "clinical method," i. e., by means of scars, history and symptomatology; the second method, which is, of course, the more scientific, deals with specimens of blood or spinal fluid and brings into consideration the results of the Wassermann blood test.

But, at best, as just remarked, the prevalence of disease is very much greater than was ever presented in any statistical table. How, then, can the investigator approach nearer to the truth in forming a correct estimate of the inroads of this grave malady upon the social fabric?

Statistics

This is best accomplished by studying the statistics of certain representative groups. These include the reports of examination by medical men of employes, applicants for licenses, army recruits, etc. Also by examining the records of hospitals and observing the proportion of syphilis found among patients treated in dispensaries, as well as those admitted to the wards. Thus, an estimate made by the United States Marine Hospital showed: all cases, 53,344; of these 11,414 were venereal, comprising 6974 cases of gonorrhea and 4440 of syphilis.

With the introduction of the Wassermann reaction the study of syphilis rested upon a firmer scientific foundation; for it has been found that two and a half times as many cases of the disease are found in comparison with diagnosis by the older clinical method. Has, then, the older method any uses? To this we emphatically answer "yes." The data of the bedside must and will always appeal as the logical and correct method, for when our data are computed by this method, we need but multiply the result by two and a half to find the approximate number of syphilitic cases by the most modern method at man's command.

Treatment

In the treatment of syphilis the old saying aptly applies, that medicine is an art as well as a science. Laboratory findings must never, and cannot, usurp the results of clinical findings. Injections of this or that medicament are not to be regarded as all that is required, and all cases are not to be treated alike. Per contra, syphilis is not a medical entity with an undeviating symptom-complex; but may exhibit certain morbid tendencies, inherited or acquired, in association with well-defined constitutional taints, be this alcoholism, tuberculosis, plumbism, the gouty or rheumatic diathesis, etc., that may modify the disease and demand modified or additional treatment. Syphilitic treatment is individual and never routine.

Because of the limitations of space and irrelevancy, I will not detail treatment of syphilis as concerns medicaments employed, technic of application, or the physiological effects produced; but, rather, I would emphasize the fact that at the present time the principal drugs at our disposal, in the treatment of syphilis, are mercury, salvarsan and its allied products, and the iodide of potassium.

A serious obstacle to the employment of mercury is the great length of time necessary to effect a cure. The patient rebels against this lengthy period and often disappears before the curative effect has been established.

In the early history of medicine mercury was classed as a cure for syphilis, and down through the ages this powerful drug has sustained its reputation as a cure, which in the darkened period of the world's history was widely employed by means of "inhalations" and "rubbings."

Mercurials

Beside the usual methods by mercurial treatment by ingestion, inunction, fumigation and introduction through the rectum, Scarzenio, in 1864, introduced to the notice of the profession the subcutaneous and intramuscular soluble injections, given daily or on alternate days, or by insoluble injections given weekly. The injection of insoluble preparations is made intramuscularly, although Lang, who introduced gray oil injections, made them into the subcutaneous tissue. Soluble preparations are adapted for subcutaneous or intramuscular use. The advantages by this method are, exactness of dosage, control by the specialist himself, and secrecy. The disadvantages are, pain, the formation of nodosities at the point of injection and very rarely the occurrence of pulmonary embolism.

According to Schamberg and Kolmer, the toxic effect of mercury is due to the amount of metallic mercury present in the mercurial salt and is variously manifested as a stomatitis, a gastro-enteritis, as cutaneous eruptions, or in general disorders of nutrition.

Arsenicals

The arsenical treatment of syphilis was commended to the notice of the profession by Paracelsus in 1529. Fowler's solution came into vogue in 1756, and was supplanted by the administration of Donovan's solution in 1788. In 1863 Béchamp, a French chemist, discovered atoxyl, from which was derived a whole series of organic preparations of arsenic. Atoxyl was the first of these substances to be synthesized and applied to the treatment of protozoön diseases. When the microorganism of syphilis was isolated and was regarded as a protozoon, atoxyl was energetically administered, but was soon abandoned because of the resultant optic atrophy which was prone to assert itself.

Then followed the memorable labors of Ehrlich and other German collaborators. Upon the assumption that drugs act upon an organism when they enter into chemical combination with its cells, Ehrlich developed a theory as affecting parasites in in fective diseases, namely, the trypanosomes and the spirochaetes, and asserted that the protoplasm of the parasite exhibits certain receptive cellular elements or "chemoceptors," showing a marked affinity for certain drugs and combining with them to produce death of the parasite, and he declared these effects to be parasitotropic, as distinguished from organotropic action, wherein the cells of the host were affected, producing a toxic action.

name

Salvarsan

As previously stated, the discovery of atoxyl (the a misnomer, since the term signifies "free from" or "against" poison) marked an epoch in medical science, for it and its associated substances were widely tried in the field of medicine; but the toxicity of the drug (which became to be more familiarly designated sodium arsanilate) forbade its administration, and the reputation that the new medicament had so suddenly acquired was soon lost in the disastrous results reported. Early in the present century, Ehrlich, acting upon the theory above noted, succeeded in obtaining a chemical substance that exerted a parasitotropic action, and after experimenting for the six hundred and sixth time he announced the discovery of dioxy-diamido-arseno-benzol, and in 1911 this chemical was patented under the name of Sal

varsan.

The first trials of the drug by Alt offered little

*With the announcement of this discovery, the following chemically equivalent compounds of new arsenical preparations were soon placed upon the market: The French introduced Arsenobenzol-Billon. England offered Kharstvan and Arsenobillon. Diarsenol appeared in Canada. Arsphenamine in the United States. Other closely allied products are Neosalvarsan (a modification of Salvarsan) and similarly, Neokharsivan, Novarsenobenzol, Novarsenobillon, Neodiarsenol and Neoarsphenamine. Among widely employed French preparations are: Galyl, Hectine and Sulpharsenol. Luargol contains, in addition to arsenic, antimony and silver. Quite recently the Germans introduced Silver Salvarsan. Among a large number of syphilographers, this last substance, it is asserted, is more active than neosalvarsan and, while perhaps less active than salvarsan, it is surely less toxic.