diff options
Diffstat (limited to 'old/65823-0.txt')
| -rw-r--r-- | old/65823-0.txt | 2905 |
1 files changed, 0 insertions, 2905 deletions
diff --git a/old/65823-0.txt b/old/65823-0.txt deleted file mode 100644 index e326763..0000000 --- a/old/65823-0.txt +++ /dev/null @@ -1,2905 +0,0 @@ -The Project Gutenberg eBook of The Journal-Lancet, Vol. XXXV, No. 5, March -1, 1915, by Various - -This eBook is for the use of anyone anywhere in the United States and -most other parts of the world at no cost and with almost no restrictions -whatsoever. You may copy it, give it away or re-use it under the terms -of the Project Gutenberg License included with this eBook or online at -www.gutenberg.org. If you are not located in the United States, you -will have to check the laws of the country where you are located before -using this eBook. - -Title: The Journal-Lancet, Vol. XXXV, No. 5, March 1, 1915 - The Journal of the Minnesota State Medical Association - -Author: Various - -Editor: W. A. Jones - -Release Date: July 11, 2021 [eBook #65823] - -Language: English - -Character set encoding: UTF-8 - -Produced by: SF2001, and the Online Distributed Proofreading Team at - https://www.pgdp.net (This file was produced from images - generously made available by The Internet Archive) - -*** START OF THE PROJECT GUTENBERG EBOOK THE JOURNAL-LANCET, VOL. XXXV, NO. -5, MARCH 1, 1915 *** - - - - - THE JOURNAL-LANCET - - The Journal of the Minnesota State Medical Association - and Official Organ of the - North Dakota and South Dakota State Medical Associations - - PUBLISHED TWICE A MONTH - - VOL. XXXV Minneapolis, March 1, 1915 No. 5 - - * * * * * - - - FEEDING OF THE HEALTHY INFANT[1] - - By E. J. Huenekens, A. B., M. D. - Instructor in Pediatrics, University of Minnesota - MINNEAPOLIS - -[1] Read before the Hennepin County Medical Society, Nov. 2, 1914. - -The science of infant-feeding has been revolutionized in the last -twenty years, and, in the process, it has advanced too radically in -many directions. Lately, the pendulum has been swinging backward, so -that the most advanced knowledge of today probably represents a middle -ground between extreme radicalism and extreme conservatism. In no other -direction is this more manifest than in the feeding intervals. The -religious adherence to the four-hour feeding interval is giving way -to a more rational system. I am one of the firmest adherents of the -longer interval: the food is better digested, the stomach has a period -of rest, and the general well-being of the infant is better furthered -than with more frequent feedings. But there are certain infants who -do not receive enough nourishment in this interval, especially young -breast-fed infants in whom it can be demonstrated by accurate weighing, -before and after nursing, that they receive considerably more milk -in twenty-four hours with the three-hour interval. This is the more -important in that Rosenstern has demonstrated that a large proportion -of infants up to the age of six weeks require more than the usual 100 -calories per kilogram of body-weight. One hundred calories represents -150 grams of breast-milk, so that a five-kilo, or eleven-pound, baby -should receive a minimum of 750 c.c. of breast-milk in twenty-four -hours. - -By far the best food for the healthy infant in every way--and this -cannot be emphasized too strongly--is mother’s milk. There are -certain alimentary disturbances in which it may be advisable to -replace breast-milk with certain artificially prepared foods, such, -for instance, as albumin milk in alimentary intoxication; but this is -never true of the normally healthy infant. While, as regards growth -and freedom from digestive disturbances, certain artificially prepared -foods may, when used with exceeding care, produce as good results as -breast-milk; nevertheless, this is only one function of breast-milk. -The other function which can be imparted to no artificial food is the -passive immunization of the child against infection. Ehrlich (_Zeit. -f. Hyg. u. Infectionskr._, 1892, xii, 183) has proved that antibodies, -antitoxin, and agglutinins are transmitted directly through the milk -from mother to child; and it has been shown that the blood of a -breast-fed child is considerably more bactericidal than the blood of a -bottle-fed infant. - -The practice of weaning the baby for trivial reasons has increased in -the last decade, and can be laid largely at the door of the medical -profession. For all practical purposes the only absolute indication -for weaning the baby is open tuberculosis in the mother. For the last -few years I have been making a systematic inquiry at the University -Dispensary and Infant Welfare Stations as to reasons for weaning -young infants; and in nine cases out of ten, the answer has been that -“the milk gave out.” In only a very small proportion of cases has -an ordinarily well-nourished mother insufficient milk; far oftener -the fault lies with the child. Insufficient and late development of -the sucking reflex prevents these infants from completely emptying -the breast, which in time “dries up.” This period can be tided over -by nursing from both breasts, by temporarily increasing the number -of nursings, or temporarily employing “allaitement mixte.” In cases -in which, after long, patient effort the supply of milk is still -insufficient, either supplementary or complementary feeding of cow’s -milk can be given. Where this mixed feeding is employed a minimum -amount of cow’s milk should be given; and the opening in the nipple -should be as small as possible, otherwise the child gets too much cow’s -milk, and with too little effort, and gradually refuses the breast. - -Another excuse, and one fostered to some extent by physicians, is, that -certain breast-milks are “poison for the baby.” This has even less -foundation in fact; and here again the fault must be looked for in the -baby rather than in the mother. Outside of certain variations in the -fat-content, all breast-milks are alike in composition. In proof of -this Finkelstein has fed these babies at the breast of tried wet-nurses -with absolutely no benefit, while the children of the wet-nurses would -thrive at the breast of the “poison-milk mother.” - -Abscess of both breasts may force a temporary cessation of nursing, -but the breast should be regularly emptied until the inflammation has -subsided; and then the nursing should be re-established. Cracked or -sunken nipples may render nursing impossible, but they do not stop the -flow of milk. In both these latter conditions the milk may be manually -expressed or removed with the breast-pump. In this connection I wish to -recommend the improved Jaschke pump, in which, by means of a releasing -valve, the sucking movements of the child can be very closely imitated. - -Where artificial feeding must be started early, cow’s milk is almost -universally employed. Whenever possible, “certified milk” should be -used; the ordinary milk, however, can be boiled with little or no -harm. In diluting and preparing this milk, we have the choice of -several methods. The so-called percentage feeding, favored in America, -is difficult and cumbersome, and has no advantages over its simpler -rivals. Pfaundler’s rule may be safely employed. It is as follows: -One-tenth body-weight of milk, one one-hundredth body-weight of sugar -diluted up to one liter; give 200 c.c. five times in twenty-four -hours. Even simpler is the following: One-third milk for the first -month, one-half for the second month, two-thirds for the third and -fourth months, each with the addition of 4 to 6 per cent sugar. Either -milk-sugar or ordinary granulated sugar may be employed. The malt -sugars and extracts should be reserved for sick children. After the -second month, oatmeal water may be used as a diluent in place of plain -water. - -Recently Friedenthal, a Berlin physiologist, has attempted an exact -imitation of mother’s milk, including that important element, the -salt, which had, until recently, been entirely neglected. Langstein is -very enthusiastic over this milk as a food for healthy infants; but -Finkelstein, in a personal communication, assured me that it has not -as yet proved itself. Schloss, dissatisfied with the results of the -Friedenthal milk, has modified it in the direction of casein milk by -replacing the milk-sugar with the malt preparations, and increasing -the protein content. He claims good results, and is supported by -Leopold, of New York, who has used it extensively. But we must leave -the final word as to both these milks for the future to decide. From -the sixth to the ninth month for both breast-fed and bottle-fed -babies, cooked cereals, toast, and vegetables should be gradually -added to the diet. At the ninth month, unless this is one of the hot -summer months, the nursling should be weaned, and a small amount of -cow’s milk substituted. The weaning should be gradual by omitting one -nursing period each week. The one important exception to the foregoing -rules for the first year of life, is the premature infant. In the -ninth month of fetal life, reserves of calcium and iron are stored -up in the body, which the infant gradually uses up during the first -nine months of extra-uterine life. The premature infant lacks this -store, and manifests it in different ways. As early as the second or -third month a breast-fed premature infant may develop a most extensive -craniotabes. This is not due to a true rachitis, i.e., disturbance of -calcium metabolism, but to a want of calcium in the body. Small amounts -of cow’s milk, which contains much more calcium than human milk, or -calcium in the form of calcium lactate or chloride, will remedy this -condition. A similar process happens in the case of iron. The premature -infant is born with a hemoglobin percentage of 100 to 110; by the third -or fourth month this may sink to 40 per cent, and for this reason green -vegetables should be added to the diet as early as the fourth month. - -The diet of healthy children in the second year should include cooked -cereals, vegetables, toast, cooked fruits, and meat-juices; and the -quantity of cow’s milk should be limited to one and one-half pints -in twenty-four hours. The question of the addition of meat to the -diet is important. Some authors have recently advocated the giving -of meat as early as the ninth month. During the past year, working -in Finkelstein’s laboratory, I have been able to gather some facts -which have a direct bearing on this question. (_Zeitschrift für -Kinderheilkunde_, July, 1914.) By means of the new electrometric -determination of absolute acidity (that is, the number of H ions), I -was able to show that the acidity of the stomach before the eighteenth -month of life is insufficient to permit any peptic, i. e., protein, -digestion. Solomon, working in the same clinic, in a report not yet -published, has shown the same thing from a clinical standpoint. He -found that on a meat diet up to the end of the second year large -quantities of muscle fibers passed through with the bowel-movement -unchanged; but after that age they rapidly decreased in number. It -is, therefore, worse than useless to add meat to the diet before the -beginning of the third year. - -Eggs frequently produce profound disturbances in young infants, -perhaps on account of the absorption of egg albumin, unchanged, in the -blood-stream; and they should be kept from the diet-list until the -beginning of the fourth year. - -These rules for feeding are generalized, and there may be many -exceptions. Each child is to some extent a law unto itself, and this is -especially true of those children with nervous or exudative diathesis. - -In conclusion, I wish to make a plea for greater uniformity in our -rules for infant-feeding. Even more than in strictly medical affairs -has the public the right to demand information. Heretofore, every -new book and every public lecture on infant-feeding has deviated -markedly from its predecessors, until the confused laity, and even -general practitioners, have turned in disgust to proprietary foods and -formulas. Pediatrics is a new science, and as such is bound to undergo -rapid changes and conflicting opinions. But that need not hinder us -from agreeing on certain fundamental facts which can be given as guides -to the general practitioner and to the public. - -I believe that the simple rules for infant-feeding here laid down -are neither too conservative nor too radical to serve as a basis -of agreement upon which the medical profession may show to the -public a united front on this important question. Such uniformity of -opinion--and the sooner it can be reached the better--will not fail to -have a beneficial effect on both the profession and the public. - - -DISCUSSION - - Dr. Jacob Hvoslof: I would like to ask about the value of lime-water - added to the milk. I recently had an experience where I mixed an ounce - of lime-water to a pint of milk, as I thought that would improve it. - but for some reason or other the baby would not digest his milk. After - a while I left the lime-water out, and everything went well. Whether - this is a “post” or “propter” I should like to find out. - - Dr. O. R. Bryant: In case of an exudative diathesis, where you - probably will start solids early, you will also be able to use meat - earlier. An infant that does well on solids at six months can probably - have meat once a day at fifteen months and show a normal stool. - - Dr. S. R. Maxeiner: I would like to ask Dr. Huenekens where he classes - eggs and egg albumin. - - Dr. C. G. Weston: I have been very much interested in Dr. Hueneken’s - paper. I care only for the babies during the three or four weeks after - birth; and of late years many of them have passed from me directly - into the hands of the pediatrists. I formerly had the babies nursed - every three hours, but finding that the baby specialist immediately, - on assuming charge, put them on the four-hour schedule, I changed, - about a year and a half ago, to that interval; and I thought my - troubles would cease, but such has not been the case, and it has been - my impression, as well as that of the nurses who have had the care of - the infants, that it has made very little difference. - - The four-hour schedule is not a new thing in Minneapolis. Many of the - older members of this Society may remember that twenty years ago Dr. - R. O. Beard always fed his babies in this way. - - It seems to me that we should make no hard and fast rules for the - feeding of babies, except the one that mother’s milk should be used - whenever possible. We should individualize with the babies. If they - do well on the four-hour schedule, follow it, as it makes the care of - the child easier for the mother; if, however, the child does not get - sufficient milk on this interval to properly nourish it, diminish the - latter to three hours. - - The only way to accurately determine how much milk the nursing infant - is getting, is to weigh the baby before and after nursing. One is - often surprised at the varying amounts obtained by the same baby at - different nursings with no obvious difference in the condition of the - breasts. We have had a baby obtain as much as three ounces in the - first five minutes of nursing, and at the next feeding take only one - or one and a half ounces in twenty minutes. - - The green and frequent stools, with evidences of colic, etc., are - often found to be due to too much milk, or taking it too rapidly; and - the weighing method is the only way to determine this. - - I most heartily endorse what Dr. Huenekens said with reference to the - importance of encouraging in every way maternal nursing. Many a mother - gives up the attempt to nurse her baby on account of some soreness of - the nipples or because she has thought she had too little milk to be - of any use. Most of these cases may become, by the means recommended - by the reader, good milkers, and many a baby’s life may thus be saved. - - Dr. E. K. Green: I would like to ask a question in regard to putting - babies on cow’s milk. I have adhered very closely to the principle - that modified cow’s milk is absolutely the best food for infants, if - it is impossible to get mother’s milk, but many times when I have had - the opportunity to follow these cases carefully I have had all sorts - of stomach and bowel disturbances on cow’s milk until someone would - suggest some other food, such as malted milk, or Mellin’s Food, or - even condensed milk, which seems to be the farthest from the natural - food, and then the babies would get along fairly well. Is this a - common experience, or is there something wrong with my method? We - have in our own home two children brought up on the bottle, one with - malted milk and the other with Mellin’s Food. In both these cases I - tried, not only once, but several times to use the modified cow’s - milk, but failed absolutely. I would like to know if you consider the - fault usually with the modified milk, or does the individual have - considerable to do with the case? - - Dr. A. S. Fleming: I would like to ask if in the case of the healthy - infant the mother’s diet would modify the constituents of the milk - otherwise than in the facts stated. For instance, will it modify - the character of or the percentage of the sugar, or will any of the - aromatic constituents disturb the infant’s digestion? - - Dr. M. J. Jensen: Dr. Huenekens dealt with the feeding of the healthy - infant only. I would like to ask if it is not true that nearly all - infants born alive, are born as healthy and sound as any infant - ever is, so far as the functions of its organs and tissues are - concerned? Nature frequently decides on producing premature births - and “still”-births, rather than running the risk of producing a sick - or sickly infant. In young infants it is very often difficult to - determine when to classify them as healthy or unhealthy, realizing the - conditions of their environment and usual care that is given in the - homes. - - In regard to the sterilization or boiling of cow’s milk: I do not - think that children fed on pasteurized or boiled milk develop as well - as those who are fed upon raw milk as it comes from the cow. Dr. - Palmer, of Chicago, fed seven hundred children on raw milk during the - midsummer months and only lost three of the number. The miserable, - atrophied children began to live the moment treatment with raw milk - was begun. If the process of milking was carried out in a sanitary - manner, or by means of a suction apparatus, then cooled, and placed - in sterilized bottles, I believe we would prohibit the development - of bacteria, and save the food which exerts so marked a protective - influence upon the infant’s organs. - - When raw milk free of all objections cannot be obtained, it is - sometimes advisable to use another milk product namely, buttermilk. - - Dr. S. Marx White: There is just one point I have been thinking about - in the discussion on the question of infant-feeding, and that is - whether Dr. Huenekens really means us to believe that in practically - all cases the mother can furnish sufficient milk for the child. He - passed that over in saying that in nine out of ten cases the mother - gave as a reason for discontinuing the milk that the milk gave out. Is - it not true that in a good many instances the mother needs treatment - quite as much as the infant? I do not mean medical treatment, but - management. Is it not true that an overworked, tired, nervous, - worrying mother is unable to supply sufficient milk for the child? It - has been my impression from a very limited experience in this field, - that the mental and nervous and physical state of the mother is a - very large factor in the production of the milk. When upset and under - deleterious influences she is really not a proper producer for the - child; and the management of the mother is often quite as important a - factor as any other. - - Dr. W. H. Aurand: In such cases as Dr. White just mentioned, what are - we going to do to increase the supply of milk? Also, I would like to - ask Dr. Huenekens if he means to feed to the new-born baby 200 c.c. at - a feeding? - - Dr. Huenekens (closing): As regards lime-water: I cannot recommend its - use. Wherever there is a specific demand for calcium, as in premature - infants or spasmophilic cases; or where it may help to produce a firm - stool; or, as in diarrheal disturbances, it may be of great value, but - in the normal healthy infant it is of no benefit whatever. - - Dr. Bryant mentioned the giving of meat in exudative diathesis: His - statement that such infants can probably have meat once a day at - fifteen months, and show normal stools, is beside the question. A - normal macroscopic stool does not necessarily mean that the meat has - been digested. However, I am now working on this problem, that is, to - determine whether an early solid diet produces an earlier digestion of - meat. - - I would classify eggs and egg albumin as proteins, and therefore - not digestible until the beginning of the third year: but, over and - above this, there is danger of anaphylaxis from the absorption of the - unchanged egg albumin into the blood-stream. - - What Dr. Weston says of the feeding intervals is very interesting. I - do not want to be considered an enemy of the four-hour feeding, for I - use it wherever possible, and I think it the best interval; but when - the infant cannot get enough in that period, we have to choose between - two evils. I think the lesser evil is to give the child more milk at - shorter intervals, and take the risk of a slightly poorer digestion. - We should, also, wherever possible, control the amount of breast-milk - by weighing the child before and after nursing. It is highly important - to determine whether the baby is getting too much or too little. - - As to Dr. Green’s statement, “Modified milk” is a very general term. - What is usually meant is milk with a high percentage of fat and a - low percentage of sugar, while malted and condensed milk have a high - percentage of carbohydrate. In my opinion, if he had used cow’s milk - without the addition of cream and with large amounts of cane sugar, he - would not have had this trouble. But a large number of children will - not do well on this diet. We have special rules for abnormal children - with exudative and nervous diathesis. - - In reply to Dr. Fleming’s question regarding the mother’s diet and - its effect on her milk: What the mother eats has absolutely no effect - on the composition of the milk in any way whatever, except perhaps - in the percentage of fat. Now-a-days we do not advise any particular - foods for the mother’s diet,--anything she likes, and can digest, plus - large quantities of fluid;--otherwise there is no single food we - advocate--none that will make the milk richer or better, or increase - the quantity. - - I cannot agree with Dr. Jensen that raw milk is so far superior - to boiled milk. Of course, wherever it is possible, we should use - certified milk, which does not require boiling; but, if we have - inferior cow’s milk contaminated with bacteria, we can boil the milk - with very little harm. It is just as well digested, and the food value - just as great. There is of course slight danger of scurvy; but that is - very easily diagnosed, and very easily cured by a little fresh milk or - small doses of orange juice. Where we have inferior milk, it should be - boiled in every case. - - Dr. White brought up a very interesting point in regard to nervous - mothers. Their milk supply is subject to wide fluctuations; but, - if the breasts are well emptied at each nursing, they will secrete - sufficient milk. I will admit that these cases are difficult to - handle, for the infants usually have nervous diathesis, and do - not respond well to ordinary food. The one important point is to - completely empty the breasts; and that is the only measure we can take - to increase the supply of milk. - - In reply to Dr. Aurand: I would feed a new-born infant 200 c.c. at a - feeding if the milk is sufficiently diluted. The liquid part of the - food passes very quickly into the duodenum, so that, before the infant - has finished feeding, a part of this quantity has already left the - stomach. - - In conclusion: We have an opportunity in our infant-feeding to - practice the really scientific prophylactic medicine of the future. - We can do more in preventing infant-mortality by proper feeding than - by any other single measure; and we should encourage mothers to bring - their new-born infants to the physician for advice on feeding, and - to continue to consult him at longer or shorter intervals during the - whole of the first year of life. - - - - - THE INEBRIATE[2] - By George H. Freeman, M. D. - Superintendent of the Minnesota State Hospital for Inebriates - WILLMAR, MINNESOTA - -[2] Read at the 46th annual meeting of the Minnesota State Medical -Association, St. Paul, October 1 and 2, 1914. - -The Minnesota Legislature of 1907 passed a bill establishing the -Hospital Farm for Inebriates, placing its management under the State -Board of Control, and providing for its maintenance by setting aside -2 per cent of the saloon-license money for that purpose. Later, a law -was enacted providing for the issuance of certificates of indebtedness; -and active construction work soon commenced. The Hospital was opened -on Dec. 26, 1912, with Dr. Tomlinson, formerly Superintendent of the -St. Peter State Hospital, at its head. Through his untimely death, five -months later, Minnesota lost one of her most faithful officials. The -principles underlying the work at Willmar, are, with but slight change, -those that he so earnestly advocated. - -This paper is based upon the study of the patients admitted from the -opening of the Hospital until the close of the biennial period, on July -31, 1914,--approximately eighteen months. - -Patients are admitted to the Hospital following an examination in a -probate court. In such cases there is no expense to the patient’s -relatives, except that they are expected to furnish clothing, and a -little money for the purchase of tobacco and small luxuries. Voluntary -patients are also received following their own application in a probate -court. They pay at the rate of $1.00 a day, each month in advance. No -distinction is made in the treatment of the two classes of patients, -except that a voluntary patient cannot be detained if he wishes to -leave. Any resident of Minnesota who is habitually addicted to the use -of alcohol, morphine, cocaine, or other narcotics, may be admitted to -the institution, provided the history of the patient, as furnished by -a probate court, indicates that the man can be benefited by treatment. -It is presumed that anyone can be benefited who wants to be, unless -afflicted with irremediable chronic disease. - -The requirement that the history be furnished, and the ability to -refuse admission, have kept out of the Hospital many undesirable -individuals who could be cared for only under the discipline of a -well-regulated reformatory. However, some, no matter how carefully the -history is taken, slip by. The majority of those discharged as not -proper subjects, come from that class. As there are no accommodations -for individuals suffering with tuberculosis, no one known to be -suffering with that disease is admitted. Once in a while a tuberculosis -individual gains admittance, but, if not too ill to be released, he is -discharged. - -During the eighteen-month period, 209 men and 32 women were regularly -committed; and 18 men and 3 women were received as voluntary patients. -In addition to those classified as voluntary patients, a considerable -number have, of their own volition, applied for treatment, and, -being unable to pay, have submitted to commitment, in order to obtain -treatment for their habit. - -There has been a fairly uniform increase in the number of patients -received each month, which is gratifying, as showing the need of such -an institution and also as an appreciation of the benefit that may be -expected. During the last month of the period, twenty-five patients -were admitted. - -While the causes of inebriety are diverse, it is a significant fact -that 182 patients, out of 262, assign associates as their reason for -drinking; and observation of their history clearly shows that they -have drifted along, drinking now and then and more and more each year. -A few assign illness, domestic trouble, or financial worry as a cause -for drinking. In only 6 instances was heredity noted. In 132 cases the -parents were abstainers. - -We have found it impossible to formulate any system of classification -of the unfortunates under our care. In order that some idea may be -obtained as to the number using alcohol and the various drugs, we have -constructed the following table: - -FORMS OF INEBRIETY - - Men Women - Steady drinkers 130 2 - Periodical drinkers 76 8 - Morphinism 3 11 - Alcohol-morphine 5 2 - Alcohol-cocaine 3 .. - Alcohol-heroin 3 .. - Alcohol-morphine-cocaine 3 1 - Alcohol-morphine-cocaine-heroin 1 .. - Alcohol-morphine-veronal 1 .. - Morphine-cocaine .. 1 - Morphine-cocaine-heroin 2 .. - --- -- - Total 227 35 - -The treatment of the inebriate naturally divides itself into two -stages: the treatment, first, of the immediate effects of indulgence, -and, second, such treatment as will tend to prevent a repetition of -the indulgence. The treatment of the immediate effect of alcoholic -indulgence is regarded as the easiest part of the work. While patients -are at times received under the influence of intoxicants, in no case -have they been unruly. For an obstreperous intoxicated person the -quickest soberer is apomorphine judiciously used; but we have never yet -resorted to it. Generally, a fairly rapid reduction in the amount of -alcohol consumed is made, instead of immediate withdrawal. Only in the -most exceptional cases is alcohol given over three or four days. As a -rule, during the first day it is given fairly freely. The treatment -received during this period depends entirely upon the individual; and -the treatment of one may be entirely different from that of another. -Many receive baths at a temperature of 98° to 100° F. for thirty or -sixty minutes for nervousness and sleeplessness. Some receive the -coal-tar hypnotics, veronal or sulphonal; the more restless, hyoscine; -and for others paraldehyde is used,--and occasionally chloral is used -in combination with hyoscine and cannabis indica. - -As long as he receives alcohol, the patient remains in bed and receives -only liquid diet. In cases of considerable digestive disturbance, -capsicum is freely used, but we have seldom found it necessary. - -All receive preliminary catharsis, but no attempt is made at prolonged -elimination in that way. - -For about a month tonic treatment with strychnine nitrate is used in -doses of 1-20 to 1-40 gr. three times a day. Any other medication -depends entirely upon the physical condition of the patient as revealed -on examination. Only under the most exceptional circumstances are drugs -given in alcoholic vehicle. - -In morphine or cocaine users, the reduction is usually made more -gradually, requiring a week to ten days. Generally, we find a patient -comfortable with one-half the drug he has been accustomed to taking. -In some cases we find it best to reduce the quantity to about one-half -grain, and then abruptly cease. - -Under this plan, diarrhea, cramps, restlessness, and insomnia are much -less marked. We regard the free use of the prolonged warm bath as more -advantageous to those addicted to drugs than to alcohol. Generally, it -is the only measure that seems to offer relief. We particularly do not -use hypodermic medication in any drug users. - -Heroin users, who seemingly are more numerous, receive their drug only -once in twenty-four hours. The withdrawal of the drug does not cause -the discomfort that the withdrawal of morphine causes. Vague sensations -of discomfort, some perspiration, and insomnia are met with in such -cases. - -No users of cocaine only have been met with, but in mixed forms this -drug is at once withdrawn. - -The removal of alcohol or drugs is the easiest part of the work. -Under the regular discipline of the institution, and the absence of -temptation, the great majority of patients get along without any -trouble because of abstinence. But there is the future to fear. The -patient must go out into the world again, and engage in the daily -struggle for his livelihood. One must aim to put him in such condition -that he may be able to resist the temptations that will surround him on -every hand. Our work, then, is to build up and re-educate, to strive -to form a new character, to encourage a habit of sobriety, instead of -drunkenness, to teach the man to work, to occupy himself, to obtain for -him a new outlook on life, and to teach him his duty to himself, to -his family, and to his neighbor. Here is where our difficulty begins. -Nearly every inebriate has a firm belief in his ability to abstain -from alcohol or drugs at any time and under any condition, because he -thinks he is not really responsible for the condition into which he has -fallen, and that, had not certain things happened, he would not have -been drinking. - -He is insistent in iterating and reiterating that he has now made -up his mind to stop drinking, and that is all that is necessary. -Though admitting that, for five, ten, or fifteen years, he has been -going steadily downward, he has full confidence in himself, and he -believes injustice is being done him when his parole is refused and he -learns that he is expected to remain until he has strength to resist -temptation. - -In this upbuilding of body and character the following are essential: -regularity of habits, discipline, work, food, and recreation, together -with the personal influence of the physician and those coming into -close and personal contact with the patient. - -Regular work is one of the most valuable of the remedial agents at -our command. It should be suited to the individual, and, as a rule, -should not be that to which the man has been accustomed. Particularly -is this true of the man who is used to mental labor only,--the clerk, -the physician, the pharmacist, the merchant, etc. For them out-of-door -work on the farm, lawn, or in the garden, is the very best, and next -comes indoor shop-work. We must provide something that engages time and -attention, that provides some new outlook upon life, and enlarges some -field of endeavor in which the patient has labored before coming to the -Hospital. Thus far the work has been on the farm or the improvement -of the grounds, or has been carpenter, cement, or some construction -work. The women do all the mending, and make all needed articles, such -as bedding, towels, etc. They also work in the laundry. At present we -are teaching embroidery of various kinds, no one of our patients having -ever learned any such work. - -The future must see us provided with shops, especially for winter work. -With a capacity of ninety-nine men we are able to keep them fairly well -occupied during the winter months, but any increase will have to be -cared for under special conditions. - -A very important factor is the length of time, as mentioned above under -prognosis, that a patient remains under care. As a general thing, it -is expected that the average patient will remain, approximately, six -months. The period of detention is determined only after a study of -the individual. An endeavor is made to consider all factors that may -influence the future life of the patient,--the length of time and the -amount he has been drinking, the effect on his character and physical -health, the surroundings and occupation to which he must return. Some -patients are paroled at the end of six months, some remain seven -months. Drug users require treatment for a much longer period of time -than users of liquor; and they remain from nine months to a year. The -law provides that a patient shall not be paroled in less than two -months, nor shall he be detained longer than two years without parole. -This, of course, introduces the disagreeable aspect of the work. The -detention is compulsory; and in some patients antagonism possibly -over-balances the benefit of detention. - -“One of the most pronounced features of inebriety is, however, the -inability of many inebriates to appreciate the necessity for treatment; -and the more severe the inebriety, the less easy it is first to get the -patient under treatment at all, and, secondly, to get him to remain -long enough for any treatment to have a permanent curative effect. One -has only to work among inebriates, no matter to what class of society -they belong, to know that fear of interfering with the liberty of a -subject who has no real liberty, in that he is a slave habitually or -periodically to the drink craze, results in the interference with the -liberty of all those who have to put up with his irresponsible behavior -under the influence of alcohol and other narcotic drugs. - -“Were the treatment of the inebriate only possible in a free -sanatorium, only a small minority of inebriates would come under -treatment at all, and these would be of the less severe type.” -(Pathological Inebriety, by J. W. Ashley Cooper, 1913.) - -Discipline is of great importance, but great care must be taken in its -enforcement. It is of more value for one to perform a certain duty -because one regards it either as the proper thing or as likely to -benefit one’s self or others. - -The personal influence of those who come into close contact with the -inebriate can hardly be overestimated. He is easily influenced, often -easily led, and a few thoughtless words or careless actions can undo -the result of patient work. - -All factors that may influence the future life of the patient must be -taken into consideration,--the length of time and amount he has been -drinking, the effect on his physical health and character, and the -surroundings and occupation to which he must return. Very often the -cause of the commencement of the patient’s excessive drinking may be -removed or may have disappeared. Such would favorably influence the -prognosis. - -The presence or absence of irremediable disease is important. For -instance, a woman recently committed to our care suffered from what was -supposed to be, or was, neuralgia. She still has occasional twinges of -pain; but we believe when the dentist has finished his work these will -disappear, and her prospect be reasonably bright. A man, 56 years of -age, four years ago, suffering from stone in the bladder, was given -morphine, following an operation. The bladder condition was permanently -relieved, but he became a morphine user. Such a case is a promising -one. In him the destruction of character is but little marked. - -A boy, chasing around the city, acquired the cocaine habit, and became -a loafer, drinker, and follower of loose women. For him the future -offers practically no prospect. Were he a little younger, and had the -attempt to rescue him been made earlier, there would have been much -more promise. But I doubt whether he can withstand the lure of his -former life. With a few drinks, his judgment becomes paralyzed, and he -is back to cocaine again. - -Another man, an alcoholic, a printer, became nervous and exhausted -after six months of linotype work. He probably will not get over his -drinking permanently unless he changes his occupation. - -One of the most important factors as regards recovery is the length of -time a patient remains at the Hospital. It is sheer folly to expect -that in a few short weeks a man shall have entirely recovered from the -effect of excesses extending over a period of years, to expect him to -regain a lost will power in that time. - -Another important factor is the insight a patient obtains into his -own condition. We cannot claim to make a man stop drinking. All we -can do, is to place him in such mental and physical health that it is -unnecessary for him to resort to stimulants. - - -RESULTS - -The result of treatment in a disease of the nature of inebriety, can -hardly be estimated in such time as the Hospital has been open. Our -statistics are simply offered to show possibilities. As the statute -under which the Hospital operates, contemplates a period of detention -and treatment for not less than two months,--and that period is even -too short in the vast majority of cases,--anyone resident in the -Hospital for less than two months has been placed in a separate class, -and we can learn that only two of these are doing well. Of 172 men, -aside from those who have been discharged as not proper subjects, 54 -were paroled, of whom 37, or 68 per cent, are reported as doing well, -27 were released under bond, of whom 17, or 63 per cent, are reporting. -Over one-half of the voluntary patients are reporting. - -Averaging all, we find 57 reporting as doing well; 30 fail to report; -29 are escaped, and we can learn nothing of them; and 56 were here less -than two months, 38 of these being escaped; 7 voluntary patients; and -8 were released under bond. A percentage of abstainers of 25, is to be -regarded as most excellent; and as one-third of those who have left -here are still abstaining, the greater number of failures occurring in -the first month, the outlook for the future is very encouraging. - -So far, we have been speaking of what we are trying to do for the more -hopeful class of patients. But what are we to do in the future with the -incurable, the recidivists? Are we to send them back into the world -time and again, let them abuse themselves, perchance their families, -and let them be, as it were, a constant menace to society? No, society -has a right to protect itself and to protect an individual against -himself. There should be provision made for this class. They should -be cared for in an institution under strict discipline, and made to -support themselves there and to contribute to the support of those who -may be dependent upon them. - -As soon as considerable numbers are received at an institution, the -more apparent becomes the need of means for classification, especially -as to character. It is decidedly unwise to allow the intermingling of -the young lad who has just commenced to drink, with the incorrigible or -the sodden, whose every thought may lie bestial. - -The most practical means of classification is by the use of cottages; -and it is on that plan that Minnesota’s institution has been started. -If two cottages were built at Willmar we should be able to make four -groups of patients with decided advantage to our inmates. Not more than -forty inmates should be cared for in each cottage: and I am strongly in -favor of separate rooms for sleeping-quarters, instead of dormitories. - - -SUMMARY - -The essential in the treatment of the inebriate as we meet him, is -upbuilding of body and character, which requires time, and in which -drugs play only a small part. - -Compulsory abstinence is of great value if we expect to care for a -majority of the inebriates. - -It would be wise for the State to undertake the custody, care and -control of all non-criminal inebriates in one institution, provided -adequate facilities for classification were available. - - -DISCUSSION - - Dr. C. R. Ball (St. Paul): I have been very much interested this - afternoon in this symposium on the treatment of fractures, the last - word in obstetrics, and the inebriate, only it seems to me the - Program Committee put the cart before the horse, and should have put - the inebriate first, and the other things would naturally follow - afterwards. - - Dr. Freeman has splendidly presented his work and results at the - Willmar institution. It is a subject to which I think medical men - pay too little attention. I have more and more come to look upon the - inebriate as a type of nervous disease and, in the great majority - of cases, a functional nervous disease. It may be classified as we - classify nervous diseases. We classify in one way functional nervous - diseases as to their cause,--acquired, hereditary and acquired, or - wholly hereditary. - - The inebriate may be also classed in the same way. There are perhaps a - few cases in which the habit of taking alcohol is absolutely acquired, - but they are comparatively few. There are also a few cases of nervous - prostration or functional nervous conditions from overwork, from a - depleted condition, where the nervous condition comes on; and we may - say it is acquired, and the prognosis in both of these cases is good. - It requires but little effort to put them on their feet. Then we have - that larger class of neurasthenic or functional nervous conditions, - belonging to the second group, in which the nervous disease, as well - as the inebriety, is partially acquired and partially hereditary. - There is a large class here. They have an unstable nervous system, - and whether they drink or break down depends a great deal upon the - environment and physical condition. This type of inebriate must be - treated along the same broad lines that we treat a person who is a - neurasthenic, who is subject to repeated nervous breakdowns. - - There is another type which, unfortunately, is rather large; and - this is the wholly hereditary, and in this type we may classify - the dipsomaniac. I have looked for a long time upon dipsomania as - a periodical nervous disturbance, similar to periodical attacks of - migraine or epilepsy, or periodical attacks of insanity. Often where a - son is an inebriate we find a history of migraine in the mother. Very - often there is insanity, and very often there is epilepsy, so that - when we come to consider the dipsomaniac we have a tremendous problem. - He does not drink for the fun of it, but chiefly because of mental - depression, mental restlessness, which is so great that he turns to - alcohol to buoy up his spirits and get rid of the feeling which rather - than suffer with, he would often prefer to die. I have a man of that - description who came to me, and said that at a certain time he became - depressed and suspicious, began to hate himself, went along the back - streets, absented himself from his usual associates, and always did - this at the beginning of his drinking bout. That is the case with all - dipsomaniacs. It is a disease similar to epilepsy, and our success in - treating this type is just about as good as in treating epilepsy. It - is not the alcohol: it is an inherited condition; it is a periodical - nervous disturbance, just as epilepsy and migraine are. - - We hear a great deal about the prevention of tuberculosis, and much is - done to prevent it. I think we hear much more about the evil effects - of syphilis than of alcohol, but, in my experience, I would place - alcohol at the top of the list as being the most damaging both to the - individual himself and to his offspring. We have heard a great deal - about the effect on the offspring. In my clinic at the Free Dispensary - I have many epileptic children, and I should say in sixty per cent - of the cases one parent is an alcoholic. An address of Dr. Rogers, - of Faribault, with reference to the ill effects of one intoxication, - when a conception occurs during that time, put the subject of drinking - before me in a new light. Much interesting experimentation has within - recent years been done with rabbits and guinea-pigs to show the - harmful effect of a single dose of alcohol given to either the male or - female parent before conception, on the after-coming litter. - - Not long ago I read an article by some man in New York in which he - stated he had traced seven cases of epilepsy to the evil results of - a single intoxication in seven different parents. That was something - rather new to me, as I thought, in order to get the bad effects, - on the descendants, of alcohol, it was necessary to be a chronic - alcoholic, and I believe very few of the laity understand that, - if conception happens to occur during one drunk, the parent being - otherwise a temperate person, the ill effects may be visited on the - offspring to as great an extent as if the parent were a chronic - inebriate. These are some of the things which would do good if given - publicity. - - In regard to the treatment: I can fully agree with Dr. Freeman in - everything he has said. There is certainly no specific when you come - to consider the nature of the trouble. The treatment must be carried - along the same general lines of physical and moral upbuilding as those - we seek to follow in functional nervous disease. - - Dr. W. A. Jones (Minneapolis): I wonder how many members of the State - Association have visited the hospital for inebriates at Willmar. I - would like to ask all those who have, to hold up their hands. Five - or six of this audience, representing the twelve hundred doctors - belonging to this Association. That gives one a fair estimate of - those familiar with the State farm for inebriates. I should like to - know further how many members of the legislature have visited this - institution, and how many have tried to condemn it or perhaps to take - it for a tuberculosis hospital. That is what they will do unless we - physicians stand by Dr. Freeman and the institution. - - There is too much sentiment, too much sympathy among friends, - relatives, courts, juries, and charity workers, as to the inebriate; - but once he gets to Willmar and is under a proper regimen, his - attitude changes totally toward himself and toward the world. After - one has watched the treatment at Willmar and has seen the benefit - these patients derive, he wonders why so many women and so many men - are sent to quack institutions for inebriety and drug habits. Willmar - costs the patient practically nothing, except a small per capita - borne by the State. The average quack institution charges $150.00 for - a cure, so called, whether the cure lasts for three days, or, as in - some of the more conservative (?) quack institutions, the period is - extended to ten days, and in the notoriously drink-habit cures, to - thirty days. This ought to appeal to a doctor forcibly, inasmuch as - all these claims of cures made by quack institutions are limited to - thirty days at the outside, an absolutely absurd statement, and, for - that reason, if for none other, we should all support and entertain - anything that tends to increase the efficiency of the State farm for - inebriates at Willmar. - - One thing which Dr. Freeman wants to emphasize is the necessity at - times of forcible restraint in a building especially constructed - for detention cases. There is a small class of people who are, - perhaps, suffering from a disease state, who are irresponsible. Most - of them are common drunkards, who create all sorts of disturbances - and who really need discipline--who need to be detained forcibly - for a sufficient length of time to enable them to recover their - normal physical tone, and until they recover something of their - natural mental tone. If this could be incorporated in the rules and - regulations of the governing body of the inebriate farm it would make - a great increase in the total number of improvements and recoveries. - - Dr. Freeman has emphasized the necessity of getting the physical - condition up to a high point. He has said all that is really needed - on the subject. I believe drugs and drink should be reduced rapidly - in almost every case. If you look over some of the literature of some - institutions that take these people, you will find they reduce the - morphine down from fifty grains to forty, and then to thirty-nine, - until, finally, after a period of so many weeks or months, they cut it - down to the two-hundredth of a grain, and give it hypodermically. You - can readily see the absurdity of that treatment. The average man can - have the total reduction made within thirty-six or forty-eight hours. - - I hope you will take more interest in the inebriate farm, and see that - your legislator is interested as well. - - Dr. Haldor Sneve (St. Paul): I have listened with a great deal of - pleasure to Dr. Freeman’s paper, and especially because there are some - statistics as to what can be accomplished in such an institution even - in a comparatively short time. Personally, I think that six months as - an average time to stay in this institution would be too short. It - will be found, however, in time, whether this is true, but just now - the institution is in the experimental trial stage. - - A great many legislators are, as Dr. Jones said, trying to convert - this institution either into an insane asylum or a tuberculosis - sanatorium; and it is up to the profession of the state to back up the - establishment of this institution for the treatment of a class which - is growing. - - Personally, I think drink is a vice and not a disease, and until we - can eradicate from the minds of the laity and from the minds of some - physicians the idea that a man who drinks is some sort of a nervous - invalid, the sooner we shall get better results in the handling of - this question. Even the dipsomaniac has periodic brain-storms, which - Dr. Ball has likened to attacks of migraine; that is a good simile, - they do not always take to drink, but go off in other ways. - - I have treated from twenty to fifty cases of delirium tremens at the - City Hospital every year for twenty years, and I have had considerable - experience in institutions; and yet I cannot find anything to - criticize about the principles of treatment that Dr. Freeman has put - forth here today. The idea in the minds of the laity is that inebriety - is a disease, and they want drugs for it to make them well, and - that is one reason why so many patients go to Keeley cures and get - well. They go there because they find a drug that cures _disease_. - I find that the Towne-Lambert treatment is an excellent _mental_ - treatment for the inebriate in private practice. It can be used in the - institution at Willmar, as well as in private practice, and putting a - patient upon the Towne-Lambert treatment satisfies his desire to cure - the disease he is suffering from. - - I think the profession will have to keep their eyes on the - legislators, perhaps on the new governor, and see that this - institution is not thrown into the waste-basket, so to speak, or - converted into some other sort of institution, because we need a place - of this kind. Even if Minnesota can go prohibition pretty soon--and I - rather think it will--we shall not get rid of our drunkards for that - reason. We shall still have to have a hospital for the treatment of - the morphine, cocaine, and alcoholic habits. The doctors who send - patients to Willmar, I think, ought to be careful, and not try to - help some municipality out of taking care of old battered hulks, who - cannot hope to recover, who cannot be made well simply because they - have been drinking for so many years, and their other habits of life - have resulted in such a deterioration of the brain that there is no - possibility of bringing them back and making really good citizens of - them. Those patients should be kept in a work-house or in a special - department at Willmar or some other place. We should try to reclaim - all of our young men and young women habitues. - - Owing to the absence of proper writeups about this hospital it is not - generally known throughout the state that pay-patients can be received - and treated just as in any sanitarium and at very moderate rates. - - Dr. Freeman (closing): I really have nothing to add in closing except - to say a word with regard to prohibition. I have a second-hand - statement from the police of one of the Twin Cities that he is - positive in his city there are five thousand drug-users from his - experience in the police court. - - With regard to the maintenance of discipline at the institution: We - have sufficient law or authority for discipline, but we have not - the facilities. The thing in my opinion that we mostly require is a - building where we can take care of a man who is incorrigible, or a - man who runs away. For two reasons: In the first place, I have known - a number of men who came there unwillingly, who later were greatly - benefited by their compulsory stay; second, the effect of disciplinary - measures upon the population in general. If a man knows that, when he - goes there, he must stay, he naturally gets over his constant thought - that he is going to sneak away, and put it over. The custodial cottage - to take care of forty people would allow, in all, four classes of - patients. We should have a reception-ward in which to examine all new - patients; one ward for the incorrigible; and we should have two other - places to care for two classes of men received. This would prevent the - influence of the older men who have gone further in their habits upon - the young boy who has just started. - - - - - DIAGNOSIS OF INTRACRANIAL COMPLICATIONS IN DISEASES OF THE MIDDLE - EAR AND ACCESSORY SINUSES OF THE NOSE[3] - - By Joseph C. Beck, M. D. - CHICAGO. - -[3] Read before the Sioux Valley Medical Association, July 22, 1914, -and published in these columns at the request of the Association. - -The most important causes of intracranial complication from the middle -ear and nasal accessory sinuses, are suppurations, consequently I shall -confine my remarks to that subject, and not take up the neoplasms, -trauma, etc. - -In the diagnosis it is most important to recognize suppurative -disease of the ear and sinuses, but this subject is not within the -province of this paper, therefore I shall satisfy myself by mentioning -only that the presence of the pus from the middle ear and nose, -and Röntgenographic examination, are the most important signs of -affections of these structures. The one symptom more than any other on -the part of the patient of a threatening extension into the cranial -cavity, is localized pain or headache, which is very persistent, -instead of periodic. Especially important is this in connection with -the cessation or diminution of the discharge. The knowledge of the -pathological change present in the sinuses and middle ear and mastoid, -is of additional value as, for instance, tuberculosis, syphilis, and -cholesteatoma. - -The frequency of intracranial complication in suppuration of the -middle ear is much greater than that following sinus disease, about -twenty-five to one in my experience. - -The intracranial complications which I shall consider are-- - - 1. Meningitis. - 2. Sinus thrombosis. - 3. Brain abscess. - -The meningitis may be serous or suppurative, and later localized or -diffuse. - -The sinus thrombosis may be partial or parietal, and complete with or -without involvement of the jugular bulb and vein. The brain abscess -may be extradural or genuine within the brain substance proper. The -complications may be further divided as to bacteriologic or etiologic -factors as, for instance-- - - Streptococcic - Staphylococcic - Pneumococcic - Tuberculous - Syphilitic - -These complications may arise following acute, or chronic and acute, -exacerbation of chronic suppuration of the ear and sinuses. Meningitis -and sinus thrombosis (this latter condition is very frequently -associated with a localized meningitis) are usually complications -following acute, or acute exacerbation of chronic, suppuration of the -ear and sinuses. Brain abscess, however, is most frequently associated -with the chronic form of the ear and sinus disease; but these become -more manifest following an acute attack of ear or sinus trouble. -Tubercular or syphilitic meningitis is chronic inflammation _per se_; -but these conditions are also lit up by the acute processes within the -ear and sinuses. - -The cardinal symptoms of any intracranial complications are-- - - 1. _Pain or headache._--This may be localized or diffuse; it is, - however, very persistent and quite intense. It is in the recognition - of this symptom that has helped me more than any other in suspecting - intracranial trouble. - - 2. _Nausea and vomiting._--This symptom is quite constant, especially - early in the disease; and projectile vomiting is quite characteristic - of intracranial pressure or irritation. - - 3. _General septic appearance._--This of course will vary in the - different conditions under consideration, but in all is it quite - manifest. - - 4. _The vision_ is very frequently affected due to the choked disk - that is present. - - 5. _Temperature, pulse, and respiration_ are very frequently disturbed. - - 6. _Definite focal symptoms_ of brain localization are of the utmost - importance in the diagnosis. - - 7. _Blood and spinal fluid examinations_ give very valuable - information. - - 8. _Röntgenographic findings_ are at times valuable. - - 9. _Exploratory operation and treatment_, as in lues, is at times - necessary to make a diagnosis. - - -MENINGITIS - -(a) _Serous meningitis._--One of the first signs is the increasing -headache, at first localized, usually near the seat of the perforation -or path of infection, and soon becoming diffuse over the head. The -patient loses his appetite, his tongue becomes coated, the emunctaries -become sluggish in their action, and nausea is a very common symptom. -The temperature rises, and, if the septic form is going to follow, this -rise is often quite rapid, so that there may occur small chills from -the infection of the cerebrospinal fluid. The pulse and respiration -rate is now considerably increased. The patient is very irritable and -restless, and does not sleep. As soon as the fluid increases within the -cavity there is observed the characteristic syndrome of rolling the -eyes, especially upward, the neck is drawn backwards, and finally the -leg upon the thigh and thigh upon the abdomen. Attempts to straighten -them out is resisted and appears to be painful,--Kernig’s sign. - -Stroking the bottom of the feet with some semisharp instrument -or the finger-nail will cause the big toe to turn up instead of -down,--Babinski’s sign. - -Taking the head and tilting it forward against the chest will cause the -limbs to be drawn up,--Brudzinski’s sign. - -All the other symptoms, as pressing over the peroneal nerve and muscle -(Gordon’s sign), which will cause the extension of the toes, the -stroking of the anterior tibial surface (Oppenheim’s sign), or the -stroking of the region of the external malleolus (Chaddock’s sign), -will produce retraction of the toes. All these signs, I say, prove that -the upper neuron (within the cranium) is involved. The patient now will -lapse into unconsciousness, and be roused with more or less difficulty -to again relapse in the same condition. The pupils become sluggish in -their action, at first becoming small, then irregular, and finally -dilated. - -Ophthalmoscopic examination may reveal a choked disk. Spinal puncture -shows increased pressure by fluid very frequently coming through the -hollow needle with a spurt, and clear or slightly cloudy. Following -such a puncture the patient is very often much improved for from a -half an hour to a whole day, but the symptoms soon return. A complete -examination of the cerebrospinal fluid thus removed, will aid a great -deal in diagnosis. This includes the following: - - 1. Remove about 25 c. c. at spinal puncture. - - 2. Make several slides and stains for organisms, as septic and - tubercular. - - 3. Examine and count the endothelial cells, leucocytes, and pus cells. - - 4. Make cultures. - - 5. Make a Noguchi (butyric-acid) test for excess of albumin. - - 6. Make a Lange colloidial test. - - 7. Wassermann, Nonne, and Noguchi tests for syphilis. - - 8. Test for sugar. - - 9. Test for total acidity and relative acidity. - - 10. Cholin may be tested for. - -In the serous form one will find the cells increased somewhat, -especially the leucocytes, but the micro-organisms are conspicuous by -their absence. - -The Lange (colloidal-goldchloride) test will show the characteristic -color reaction of a septic process. - -The Noguchi (butyric-acid) test will be positive. Excess of albumin. - -The Wassermann, Nonne and Noguchi tests for syphilis are negative. -(Unless such a case should be a complicated one.) - -The test for sugar is very important in that in serous meningitis sugar -is present. - -The relative acidity is not markedly affected, and cholin is not -present, or, if so, in only small quantity. - -(b) _Septic meningitis._--If this is _localized_, and there is a -collateral serous meningitis associated with it, then the symptoms may -be the same, as just described; however, the cerebrospinal fluid will -show a greater degree of irritation, and the fluid may contain some -micro-organisms. The majority of localized septic meningitis cases, -however, are not as severe in their course as the serous or diffuse -septic forms. The one important symptom is the localized headache, -which is quite persistent, and the greater rise in the temperature. -There are, undoubtedly, many cases of localized meningitis that show a -perfectly normal cerebrospinal fluid, and most of the cardinal symptoms -absent; and these are the cases that usually get well or lead to -extradural abscesses subsequently. - -The _diffuse septic meningitis_ is the most discouraging intracranial -complication that we have to deal with, and the diagnosis as a rule is -not difficult. It usually is preceded by the serous form, but within -a very short time develops the graver symptoms of sepsis. The most -positive symptom is the spinal puncture. The fluid comes out under -pressure, but not so great as in the serous form, and is turbid. -The turbidity varies in degree with the amount of infection. It has -the appearance at times of pure pus; in fact, that is what it is. -Bacteriologically one will find many micro-organisms of the character -of the infection; and leucocytes or pus cells are very numerous. - -The sugar reaction is always absent, and the acidity is much increased -as is the quantity of cholin. - -The pressure or irritative symptoms as the Kernig and Babinski tests, -as well as the pupillary reactions, are practically the same as in the -serous meningitis, only that they soon give away to the paralytic form, -namely: pupils dilate, patient is in a constant stupor or coma, and -the involuntary urination and bowel movements become very manifest. -The patient is, as a rule, unable to take or be given nourishment. The -outcome is, in my experience, with one exception, always fatal, due -to diffuse cerebritis. I have had a case of diffuse septic meningitis -in the early stages of a pneumococcic type which I operated on by the -Haynes’ method of drainage of the cyscterna magna, and which recovered; -and I believe that the success in that case was due to the very early -intervention, because I have operated by the same method on eight other -cases more advanced and of streptococcic and staphylococcic type of -infection, which ended fatally. - -_Sinus thrombosis._--This complication is the one that is recognized as -giving the best prognosis because it can be very readily recognized, -and even exploration is warranted to make such diagnosis. It most -frequently follows, or is associated with, acute infections of the -middle ear and mastoid process. The most important symptoms are the -chills and fever of a distinct septic type, and, as a rule, increasing -in frequency. There is invariably a blood-picture of sepsis, namely, -a very high leucocyte count and the polymorphonuclear type in marked -excess. Blood cultures are, as a rule, positive of a bacteriemia. If -the process has extended to the bulb and internal jugular vein, then -one may feel a thickening or cord-like mass along the anterior border -of the sterno-cleido-mastoid muscle. The fundus examination often -reveals a choked disk, especially on the side where the thrombosis is -located. A symptom recently described by Beck, of Vienna, and Crowe, of -Baltimore, and proven by me to be of positive value in several cases, -is the production or increase of a choked disk by compression of the -healthy internal jugular vein. Urbanschitch has shown in quite a number -of cases of sinus thrombosis that the blood-clotting time is very much -enhanced. This of course is true of any case of bacteriemia or septic -phlebitis anywhere in the body. I have proven this test to be of value -to me in several cases of sinus thrombosis. The exploratory exposure of -the lateral sinus is of distinct value, and the only fact to remember -is to expose a sufficient area so that one is able to deal with the -sinus in case it be opened accidentally, because such an accident when -this precaution was not taken has led to serious consequences. - -The diagnosis of a thrombotic sinus when exposed is made first by its -discoloration, usually of a grayish pink; secondly, it feels harder -than normal and is not resilient when compressed, that is, it does -not spring back. It, however, may be soft in case the thrombus has -broken down; and in cases of parietal thrombosis it may spring back -because there is blood circulating through it. One will at times -find a small collection of pus about the sinus, a condition known as -perisinus abscess, and in many instances of this condition the sinus -itself is not thrombosed. The puncture of the sinus by a hypodermic -needle and attempt to withdraw some blood, is not at present considered -good practice owing to the danger of infecting a non-infected sinus. -An incision is considered a wiser plan, and subsequently packing -both sides (torcular and bulb) so they are shut off from the general -circulation. There are many instances of secondary infection by -embolism, either in or about the joints, and infection into the lungs, -spleen, pancreas, etc., with the entire train of symptoms from such -complications. - -_Brain Abscess._--This is most frequently associated with chronic -suppuration of the middle ear and mastoid, and labyrinthine disease. -As stated before, we must consider two principal types, namely, those -outside the dura and those within. They may exist at the same time, -or the intradural abscess may frequently follow, especially in acute -exacerbations, the extradural abscess. The paramount symptom is the -great pain in the head, most frequently localized at or in close -proximity to the abscess. I have, however, found several instances -where the patient located the pain in the anterior portion of the head, -and operation or post-mortem examination disclosed it in the posterior -cerebral fossa. This pain is not at all unlike that in brain tumor, -and there are exacerbations in the headaches sometimes at night, other -times in the mornings, and in one of my cases the patient would have -about ten attacks of severe head-pains within twenty-four hours, and in -the intervals be fairly comfortable. - -The next group of symptoms of importance are the focal lesions, which -will correspond to the anatomicophysiologic locations and actions. -These focal symptoms will vary in degree in that they be either -irritative or destructive. So, for instance, a small abscess pressing -over the motor area will cause clonic contraction and a still larger -abscess, especially if it be intradural, will produce paralysis of -that portion of the body governed by that particular area. Again, -if it be located in the cerebellar region it will cause a train of -symptoms of imbalance and loss of interpretation of direction, which -must be carefully differentiated from the irritation of the labyrinth. -In this department there has been much work done by Barany, Ruttin, -Neumann, and other Viennese, and many others to make it possible to -make a differential diagnosis; and there is a great deal more to be -done. One of the most important recent contributions in this regard is -the “pointing test” of Barany in connection with cerebellar lesions; -and careful study and experimenting at every opportunity is very much -recommended, in order to familiarize one’s self with this test. This -in connection with the various labyrinth tests makes the differential -diagnosis much more easy. One must remember that both labyrinthian -irritation in connection with suppuration of the ear and cerebellar -irritation from brain abscess may exist at the same time. - -_Intracranial pressure_, being increased in brain abscess, will -cause the cerebrospinal fluid to be increased and found to be so by -spinal puncture, although no pus cells or micro-organisms will be -found, unless there is also a concomitant diffuse septic meningitis -or ventricular infection present. The ocular symptoms of intracranial -pressure, such as pupillary (often one large and one small) and -choked disk, are usually present. The _pulse rate_ and _respiration_ -will be affected, as in brain tumor, according to the size of the -abscess. The larger the abscess the slower the pulse and respiration. -The temperature, as well as the pulse and respiration, will vary -as to whether the abscess be intradural or extradural. Intradural -abscesses will frequently cause considerable rise of temperature, and -acceleration of the pulse and respiration, and a remission when the -abscess has become partially walled off. As soon as a fresh invasion of -brain tissue takes place another rise of temperature, etc., occurs. - -_Projectile vomiting_ is, as in brain tumor, quite frequently -encountered. - -_The Röntgenogram_, especially a stereoscopic one, will be of some -value in cases where through its chronicity a change of bone by -pressure has taken place, or if one may follow the path of necrosis -from the nasal accessory sinuses or the middle ear and mastoid process -towards the brain. I will state, however, as I have stated on several -occasions before, that not too much emphasis should be laid on the -diagnostic value of the _x_-ray in intracranial lesions, especially -abscess. I have been disappointed in this great method of diagnosis -(_x_-ray) and much annoyed at the positiveness of some observers -without sufficient evidence. - -As in sinus thrombosis, so in brain abscess one should not hesitate in -the exploratory operation, because waiting too long will often reduce -the patient’s ability to stand an operation later on. Should one not -find the abscess, then the decompression has done a great deal to -prevent destruction of brain tissue by pressure, besides the patient -will be very much relieved of the severe head-pains. This may be said -also of spinal punctures. In this way one may wait for development of -localization for another operation. - -In conclusion, I would like to repeat the words of Prof. Neumann as -to the differential diagnosis between meningitis, sinus thrombosis, -and brain abscess: “A patient that has meningitis is one that wishes -to be left alone and allowed to sleep, although when roused is not -particularly irritable. If he has brain abscess then he is constantly -very irritable and difficult to manage, while a patient that has sinus -thrombosis when he is free from the chill and fever is very pleasant, -apparently well.” - - - - -THE TREATMENT OF GONORRHEAL OPHTHALMIA - -Arthur Edward Smith, M. D. MINNEAPOLIS - - -In ophthalmology, as in other branches of medical science, the advance -in therapeutics has hardly kept pace, in recent years, with that -in pathology and diagnosis. Comparatively few of the therapeutic -innovations of the past decade have stood the test of time; and, in the -main, the ophthalmological materia medica of today bears a striking -resemblance to that of fifteen or twenty years ago. Our poverty of -therapeutic resource has been notably exemplified in the generally -accepted method of treatment of gonorrheal ophthalmia; and the results -obtained with the conventional treatment as outlined in the current -text-books are far from satisfactory. - -Gonorrheal ophthalmia, in both infants and adults, continues to cause -an appalling amount of blindness; and only a part of this can, with -justice, be ascribed to ignorance and neglect. The number of cases -which, in spite of the most careful treatment, go on to corneal ulcer, -perforation, panophthalmitis, and irreparable blindness, continues to -be considerable. Further, a decided difference of opinion still exists -among well-trained oculists of wide experience as to the best method -of handling these cases. For over a hundred years silver nitrate has -enjoyed an unquestioned pre-eminence in the treatment of the purulent -ophthalmias, particularly those cases in which the gonococcus was the -etiological factor; and even now to question its right to a place in -the treatment of gonorrheal conjunctivitis seems to many to be as -heretical as to abandon mercury in the treatment of syphilis. For -many years the only difference of opinion in regard to silver nitrate -seemed to be as to whether it should be employed in the first stage -of the disease, or whether one should wait until the discharge became -purulent. Of late years, however, a number of experienced oculists -have gone on record as being of the opinion that the majority of these -cases do distinctly better without the nitrate than with it. As is -well known, the nitrate destroys only those gonococci lying upon the -surface or in the most superficial layers of the conjunctiva; and, far -from reaching those in the deeper layers, rather forms a film over the -surface which protects them from the irrigating solution used later. -It also appears to be certain that the use of the nitrate, for a time -at least, increases the ratio of extra-to intracellular gonococci in -the discharge, which furnishes another valid argument against its use. -That a subsequent chronic conjunctivitis with hypertrophy is often a -disagreeable sequel in cases in which an energetic course of silver -nitrate has been used is a matter of common observation. The vogue of -certain of the organic silver salts, such as argyrol, protargol, etc., -is no doubt, not so much due to any intrinsic therapeutic merit which -they possess as to the fact that the average case gets along better -without the local application of strong chemical antiseptics. However -one may feel about the abandoning of such a time-honored drug as the -nitrate of silver in the treatment of this disease, it must be conceded -that it is entirely inadequate to control the process in the severer -cases, and as a therapeutic sheet-anchor leaves a great deal to be -desired. - -The use of cold compresses in gonorrheal ophthalmia continues to be -advocated in text-books and practiced in many clinics, especially in -America, in spite of the fact that the progressive men in general -medicine and surgery seem pretty generally to have abandoned the use of -cold applications in the treatment of acute inflammations of bacterial -origin. Any merit the cold compresses may have in the reducing of the -edema and relieving pain are more than counterbalanced by the fact that -the vitality of the tissues is at the same time lowered. In cases in -which there is a sufficient swelling of the lids to cause a dangerous -pressure on the eyeball, cold should not for a moment be depended -upon to control the inflammatory edema but instant recourse had to -canthotomy: in cases where this swelling is not marked cold compresses -are unnecessary and apart from a certain analgesic effect, of no -value. The skepticism, which is becoming more general, in regard to -the value of silver nitrate and cold applications has not extended to -the third member of the classic trinity,--irrigations,--the efficacy -of which seems to be generally conceded. Various substances have been -advocated for this purpose,--boric acid, potassium permanganate, -bichloride of mercury, normal salt solution, etc., and the consensus -of opinion seems to be that it is practically indifferent which one -of these is used, the action being mechanical rather than chemical. -The ordinary method of half-hourly irrigations has been abandoned by -Hosford, Ulbrich, and others in favor of the constant irrigation with -the Hosford apparatus or some modification of it. - -The English adherents of the constant irrigation treatment, who, for -the most part, dispense with the use of silver nitrate altogether, -report excellent results; but the method is not without its drawbacks. -The apparatus is awkward to use, requires as much or more attention -than the intermittent irrigations, and undoubtedly disturbs the rest of -the patient at night more. Further, since the lids are, of course, not -held apart for the constant irrigation, but the flow of the solution -across the palpebral fissure is depended on to cleanse the eye of -secretion, one is inclined to question whether the mechanical cleansing -is as thorough as when the lids are gently held apart while the eye is -being irrigated. - -The more one sees of these cases, the more one is impressed with two -things: first, that a certain percentage of them would make a complete -and uncomplicated recovery, even if they were entirely untreated -(undoubtedly this number is larger than we think, especially in -children); second, that the usual treatment is entirely inadequate -in those cases in which there is an especially virulent infection or -a lowered resistance of the tissues. When antigonococcic serum was -first developed and its action observed in cases of acute gonorrheal -ophthalmia, the results were, as in acute urethritis, disappointing. -Many oculists are of the opinion that the serum is entirely without -value in acute blenorrhea, even though its use be indicated in -metastatic eye disease of gonorrheal origin. Of late, however, at least -two men in America have written enthusiastically of serum-therapy in -acute gonorrheal conjunctivitis, advocating its employment in the usual -manner and also its use locally, i.e., dropped into the conjunctival -sac in place of the usual antiseptics. It would seem that the data -now available hardly warrant a positive statement in regard to the -serum-therapy. - -The pathological findings in gonorrheal ophthalmia are simple but -significant, in that the gonococcus of Neisser is found, not only -on the surface and in the superficial cells of the conjunctiva, but -also, often within forty-eight hours, has invaded the deeper layers of -the epithelium and the subepithelial connective tissue. This at once -makes clear the reason for the inefficacy of the local antiseptics, -particularly those like silver nitrate, the action of which is very -superficial. Organic silver preparations and irrigations of various -kinds are equally powerless to reach any but the most superficially -situated of the bacteria. - -Since the destruction of the bacteria lying on the surface is not -sufficient to control the disease, it may be stated that the problem -of the destruction or inhibition of the deep-lying bacteria is the -essential problem in curing gonorrheal ophthalmia. - -The gonococcus numbers among its biological peculiarities an unusual -intolerance of extremes of temperature, its growth in culture being -inhibited by temperature above 38° C. or below 18° C. Text-books on -bacteriology state that exposure to a temperature of 60° C. for a -period of ten minutes destroys the gonococcus. Experimentation in the -laboratory of the Dimmer Clinic in Vienna in April and May, 1913, with -cultures from forty-two cases of acute gonorrheal urethritis, seemed -to indicate that this point may be placed from one and one-half to two -degrees lower than this, i.e.,--from 58° C. to 58.5° C. - -Thus, theoretically, at least, it would appear that, if the conjunctiva -could be subjected to a temperature as near as possible to this -without injury to the tissues, a marked effect should be observed in -the course of the disease, particularly if the heat can be applied -in such a way as to penetrate as deeply into the tissues as does the -gonococcus. This theoretical requirement has, in my opinion, been -perfectly met practically by the local use of steam as practiced in -the Dimmer Clinic since February, 1913, with the apparatus devised by -Lauber and modified by the writer. Goldzieher of Vienna was probably -the first to employ steam in the treatment of the purulent ophthalmias; -and in his first series of cases reported fifteen patients treated -with the application of steam passing through a nozzle held at a -distance of about four centimeters from the eye, the temperature of -the steam striking the tissues being about 45° C. (113° F.). Although -the results indicated that the method was a distinct step in advance -there were still a number of important details to be worked out, in -order to get the best possible results. First of all, experiment -showed that the temperature of the steam at a given distance from the -nozzle was not constant, so that an arbitrary distance could not be -set. This suggested the advisability of providing the apparatus with a -sliding-guard, which could be set at the exact distance from the nozzle -where the steam was shown by the thermometer to be at the desired -temperature. Secondly, it was determined that the tissues would sustain -without injury a considerably higher temperature than that set by -Goldzieher, and that the effect upon the diseased process was markedly -better when the temperature was raised. Steam at from 50° C. to 53° C. -gave the best results; and in one case in which a temperature of 55° -C. was inadvertently reached no injury was done the tissues. Further -experience naturally suggested other changes in the original technic. -In the first place, the lids were held apart by an assistant in the -usual manner; but, even with gloves on, the exposure of the fingers to -the steam was more or less painful, and gauze wound on little sticks -was substituted. The time of exposure was finally set at six minutes; -and since the application of the steam could not be borne for longer -than from forty-five to sixty seconds without severe pain it usually -took twenty minutes or so to complete the six-minute exposure. This was -done once every twenty-four hours, and was combined with half-hourly -irrigations with potassium-permanganate solution. No other treatment -was used. The results attained with this method in 34 cases (7 adults, -2 children and 25 infants) has left nothing to be desired. In no case -has there been any corneal complication; swelling and pain subsided -with unusual promptness; and the course of the disease was notably -shortened, whereas, after the first application of silver nitrate a -considerable increase in the number of gonococci in the discharge is -often observed. A striking diminution in the number is noted after -the initial application of the steam. In 8 of the cases in the series -mentioned (all infants), the disease affected both eyes; and in 5 of -these cases the experiment was made of treating one eye with steam in -the manner described and the other with applications of silver nitrate -in the usual manner, using the permanganate irrigations in both. The -difference in the results attained was very striking. In every instance -the eye in which the steam was used was brought much more quickly under -control than the one under nitrate. In cases brought under treatment -early the edema of the lids did not become severe; and the course of -the disease seemed, in general, to be shortened by about one-third. -There were no corneal complications, except in one case in which there -was a corneal ulcer present when the man presented himself at the -clinic. In no case was canthotomy necessary; and no case was followed -by a chronic hypertrophic conjunctivitis. The application of the steam -is undeniably painful, but not unbearably so. - - - - - VAGINAL HYSTERECTOMY UNDER SPINAL ANESTHESIA: REPORT ON A CASE - - By R. R. Cranmer, M. D. - MINNEAPOLIS - - -I wish to report this case of vaginal hysterectomy under spinal -anesthesia on a patient whose age and physical condition were not -favorable for the use of ether or chloroform. The case belonged to that -comparatively small class in which a general anesthetic cannot be used; -and it was because of this fact that spinal anesthesia was resorted to. -Had it not been necessary for this patient to earn a livelihood by hard -labor the operation would not have been done; but, in her case, it was -necessary, and the condition of prolapse, therefore, was a source of -continual pain and trouble. The fact that the diet was not restricted -after the operation assisted greatly in shortening her stay in bed and -her rapid recovery. - - Patient, aged 59, married, mother of six children. She had been - suffering from prolapsus uteri of a severe degree for five years. The - cervix presented at the vaginal orifice at times. Mitral insufficiency - and arteriosclerosis were present. She also had chronic bronchitis and - a mild nephritis. Chloroform and ether being contra-indicated, spinal - anesthesia was used, two drachms of 2 per cent novocaine solution - being injected through the fourth lumbar interspace. The vagina was - prepared for operation, and the hysterectomy started within four - minutes after the spinal injection. The patient did not complain of - any pain; and there was no shock or other untoward symptoms. She was - immediately put upon a general diet and was able to leave the hospital - on the twelfth day. - - - - -THE JOURNAL-LANCET - -The Journal of the Minnesota State Medical Association and Official -Organ of the North Dakota and South Dakota State Medical Associations - -PUBLISHED TWICE A MONTH ESTABLISHED 1870 - - -W. A. JONES, M. D., Editor - -ASSOCIATE EDITORS: - - R. D. Alway, M. D. Aberdeen, S. D. - H. J. Rowe, M. D. Casselton, N. D. - -PUBLICATION COMMITTEE: - - THOS. McDAVITT, M. D. St. Paul - J. L. ROTHROCK, M. D. St. Paul - F. A. KNIGHTS, M. D. Minneapolis - -W. L. KLEIN, Publisher - - Subscription $2.00 a year - -PUBLICATION OFFICE - - 839-840 Lumber Exchange Minneapolis, Minn. - - - - -March 1, 1915 - -A NEW REMEDY FOR PYORRHEA ALVEOLARIS - - -Diseased teeth and gums have an undoubted and pernicious effect upon -the general health of the individual. This condition as a cause of -disease has been the subject of many papers written by physicians and -dentists. - -Now a new remedy has been proposed by Bass and Johns which promises -relief in the majority of cases. Emetin is the drug that destroys the -ameba of pyorrhea just as ipecac destroys the ameba of dysentery. The -lesion should be attacked persistently until healed and the use of -emetin continued to prevent reinfection. - -Emetin may be used hypodermically in one-half grain doses for at least -three days and as often as is necessary to destroy the ameba. - -The presence of the ameba can be determined only by proper microscopic -examinations. The healing process may require considerable time, -according to the extent and character of the necrosis. Deep pockets -require careful cleansing to clear the pus-forming cavities. After -this has been accomplished and pus ceases to form Bass and Johns -recommend the use of fluid extract of ipecac as a local application to -prevent reinfection. Ipecac will actually destroy the ameba if used -persistently and is preferable to the many commercial preparations now -in use. The teeth should be brushed in the ordinary way, after which -one drop of fluid extract of ipecac should be applied to the wet brush, -forcing some of the solution between the teeth and spitting out the -excess without further washing of the mouth. - -The investigators have found that this simple procedure will keep -the mouth free from pyorrhea. It stands to reason, however, that the -teeth must be thoroughly cleaned in the usual manner by the dentist, -otherwise it will be impossible for the emetin or ipecac to penetrate -the deep crusts which are found about old and uncared for mouths. It -is remarkable how many people neglect the care of their teeth and it -is equally strange that so little constitutional disorder is found in -those who neglect an ordinary and simple sanitary toilet requisite. -One of the first rules for hospital patients when they come under -the supervision of the nurse is the provision of a tooth brush and a -suitable mouth wash. - -Many patients from the country, a lesser number from the cities, never -employ a tooth brush. Some even resent a suggestion of clean teeth. -Nature gave them teeth and nature is supposed to keep them in order, -but unclean teeth are the rule rather than the exception in hospital -practice. - -Not infrequently animals need the services of a dentist, but their -numbers are few compared to man. When a simple remedy for pyorrhea, -like ipecac, promises to clear the teeth of amebas, there is no excuse -for neglecting nature’s adornment. - - -LOWERING THE MILK GRADE - -A bill has been introduced in the Minnesota State Legislature for the -purpose of lowering the butterfat requirement in milk from three and -one-quarter to three per cent. This means a reduction of solids in milk -from thirteen to eleven per cent, and it further means that more water -will be added to much of the milk sold in Minnesota. A Minneapolis -ordinance prescribes the butterfat content to be as high as three and -one-half per cent. Minneapolis has enough water in its milk now, and, -if this bill goes through, the city may expect to use skim-milk almost -exclusively. - -It hardly seems credible that any one should desire the quality of milk -to be reduced for any purpose whatever unless it is for commercial -reasons. - -Fortunately, at this writing the bill is held up for consideration, -and it is to be hoped that sufficient pressure will be brought to bear -to insure its defeat. Too many cows give poor milk and any effort -to standardize and legalize the inferior cow is a reflection on the -integrity of milk sellers. Inferentially, there are too many under-fed -children and yet if milk is reduced in quality, we must expect less -vigor in the growing child. - -One wonders why such a bill should get into the Legislature; what are -the real reasons for its passage? - - -“LEAVES OF HEALING!” - -The late issue of “Leaves of Healing,” published by the Dowieites at -Zion City, near Chicago, has been sent broadcast among physicians. This -sheet is an antivaccination propaganda, and is profusely illustrated by -horrible pictures of supposed diseased states caused by vaccination. -The text is, as is all others of its ilk, full of misinformation, -garbled extracts from known and unknown writers and speakers, and -tirades against all who believe in vaccination. - -If these sheets would present a fair and broad view of the evils of -vaccination they might find more adherents to antivaccination doctrines -among medical men; but, as it contains so many misstatements and is -so overbearingly one-sided in its efforts, the effect is nil, except -when it is circulated among those unbalanced in mind and judgment. -Physicians in general freely acknowledge that vaccination, or the -introduction of a serum, may produce, in some people, unexpected and -sometimes disastrous results. Most physicians hesitate to vaccinate -people with active syphilis, or even those in whom the syphilis has -been seemingly inactive for years, or those who have hereditary -syphilis. These persons are quite apt to have an accentuation of their -old blood disorder under slight infections or injuries; but that should -not militate against vaccination when an epidemic is probable. Some -of the pictures in “Leaves of Healing” were undoubtedly pictures of -syphilis, and should have been so labeled; but that could not have been -expected in a partisan publication. - -Physicians also know that people who have chronic eczema should not -be vaccinated until the eczema clears up; and doubtless in hurried or -extensive vaccinations that are deemed necessary to prevent the spread -of smallpox in a community cases of eczema are overlooked. Children -who are the victims of chronic digestive disorders, or who react to -mild febrile or diarrheal conditions more than the average child, are -commonly exempted from vaccination. On the whole, there are but few -conditions that are made worse by careful vaccinations with proper -dressings and after-care. - -When one considers what wonders in the way of control of smallpox have -been recorded in medical history, the few mishaps that occur among -the vaccinated, the proportion of illness due to vaccination is so -infinitesimal that they cannot be classed among the “fearful” results -of vaccination. - -“Leaves of Healing” leaves out of its vaporings the fact that Zion -City had a smallpox epidemic not long ago, and was quarantined by -the health authorities, and that the people submitted to vaccination -with gratifying results. Nor does the above-mentioned magazine record -the fact that the president and secretary of a local branch of -antivaccinationists in Minneapolis, who were fighting a compulsory -vaccination law before the Minnesota Legislature a few years ago, died -of virulent smallpox during that meeting of the Legislature. - -The antivaccinationist usually has at his command a set form of -speech that contains more vituperant adjectives, and less reason and -judgment, than the average self-constituted reformer. Smallpox and -other preventable diseases will continue to exist while the uneducated -and ill-balanced minds are permitted their volley of wind-laden speech. -Some day the people will wake up, cast the “reformer” aside, and climb -on to the band-wagon of health and happiness. - -It will take our educators and sanitarians some time to harness the -team to the wagon, but when it starts it will go on merrily to its -destination. - - -OWNERSHIP OF THE JOURNAL-LANCET - -In answer to a number of inquiries the following statement is made: - -The stock of the JOURNAL-LANCET is held by a number of Twin City -physicians, and the publisher, Mr. W. L. Klein. - -The JOURNAL-LANCET is the official organ of the State Medical -Associations of Minnesota, North Dakota, and South Dakota. The -responsibility for its reading matter and editorials rests with the -publication committees of the state associations. - - - - -MISCELLANY - -To the Physicians of the State of Minnesota: - - -The Committee on Public Policy and Legislation most earnestly asks the -co-operation of every physician in the State of Minnesota in procuring -the passage of the several bills that have been decided upon, and -either have been or will be introduced into the legislature during this -session. It is believed that there is not a man upon the roster of the -State Medical Society, or indeed any physician in Minnesota, who does -not see the necessity of certain legislation for the protection of the -physicians in the State, and also that the common weal will be advanced -by the passage of the telephone bill introduced by Senator Andrews, of -Blue Earth, and by the passage of the bill relative to trachoma, which -is a constant menace to the public health, and several other bills that -are in course of preparation, but which await certain developments -before their presentation. The committee earnestly begs of all the -physicians in the State that they will write to their representatives -and senators from time to time urging with great earnestness their -support for the several measures advanced by the Committee on Public -Policy and Legislation. It is believed that every physician can -influence at least from 10 to 100 votes at a general election, and this -fact, of itself, makes the physician a factor in the election of any -candidate. It is believed by this committee that the medical men of -the State, if they will but unite and act in concert, can measurably -influence legislation. The time has come for the physician to take his -place in the political system of the State, both as an active agent -and, indirectly, through his influence of others. - -The telephone bill provides for physical connection between all -telephone companies in the State without extra charge, except a small -toll. It provides that telephone companies shall be placed under the -direction of the Railroad and Warehouse Commission. It provides that no -greater net income than 5 per cent shall be allowed upon the capital -actually used in the operation of the telephone companies. It provides -for intercity telephone service in the cities whose city limits adjoin -without extra charge. - -The trachoma bill provides for the segregation of trachomats, and, -under certain circumstances, for the maintenance by the State of -special schools for their education in school districts having as many -as 20 trachomats. - -There is also drafted and ready for introduction a bill requiring all -persons who seek to practice medicine in any form whatever to pass the -regular examination before the State Board of Medical Examiners. - -There is in contemplation a bill for the purpose of procuring certain -lands for the building of cottages thereupon and establishing farms -to be worked by lepers who may be or shall have been committed to the -leprosarium farm, the intention being that those lepers in the State -that are able to work shall have an opportunity to do so, and that the -said lepers should care for lepers who are unable to work or earn a -living. It is also proposed to purchase a small tract of land not far -from the State University for the purpose of allowing an exhaustive -study of certain forms of leprosy with the aid of the State University -Medical Staff. The leprosarium farm would be under the direction of the -State Agricultural School. - -The Chairman of this Committee will be very glad to receive advice and -suggestions from the physicians in the State. - - Cornelius Williams, M. D., - Chairman of the - Committee on Public Policy and Legislation. - St. Paul, Minn., February 3, 1915. - - - - -REPORTS OF SOCIETIES - -MINNESOTA ACADEMY OF MEDICINE - - -The Academy met at the St. Paul University Club, Feb. 3. Dr. C. M. -Carlaw presided. - -Four doctors were proposed for membership: Drs. W. H. Condit and -Stephen Baxter, of Minneapolis, and Drs. Wilhelm Lerche and F. C. -Schuldt, of St. Paul. All four names were referred to the executive -committee. - -Dr. Arnold Schwyzer showed some x-ray pictures of a penetrating gastric -ulcer. He also made a report of a case where gall-stones gave a feeling -of emphysematous crackling, due to small marble-sized stones with no -more fluid than enough to fill the spaces between the stones (perhaps a -teaspoonful in all). - -The paper of the evening was presented by Dr. A. E. Benjamin, the -subject being “Goiter Operations with Simplified Technic.” The paper -was thoroughly discussed, the whole evening being given over to its -consideration. - -The reading of Dr. White’s thesis was deferred until another meeting. - -Twenty-seven were present. - - Fred E. Leavitt, M. D., Secretary. - - - - -CORRESPONDENCE - - - To the Editor: - -In the February 15th issue of THE JOURNAL-LANCET is a discussion by -Dr. Klaveness, of Sioux Falls, S. D., on a paper on “Syphilis and Its -Relation to Society” by Dr. McLaughlin, of Sioux City, Iowa. In this -discussion Dr. Klaveness states: “We are unfortunate here in South -Dakota in this respect, that we do not have the population and the -laboratory facilities for resorting to the Wassermann reaction at all -times, and any man within the State who would systematically carry out -a Wassermann reaction now and then would invalidate his findings very -materially, inasmuch as it is very well established that, in order to -obtain reliable readings, you must have a serologist or bacteriologist -to follow this work exclusively in order to get accurate findings. It -is immensely important, and it would be a boon to the suffering people, -if we could have a state serologist.” - -This statement by Dr. Klaveness is contrary to the facts as they now -exist and did exist at the time he discussed the paper at Watertown, S. -D., in May, 1914. - -We have a well equipped medical laboratory in South Dakota in -connection with the medical department at the State University at -Vermillion, and we have been doing the Wassermann test. - -This misstatement should have been corrected at the time it was made, -but was not, as I was in Watertown but part of one day during the State -Meeting last May and did not hear the paper or its discussion. - -Permit me to state through your columns that we do the Wassermann test -at the State Health Laboratory and have been doing it on Thursday -of each week since March 21, 1914. At that time a circular letter -announcing the fact was sent to every physician in the State, including -Dr. Klaveness. This announcement was made only after several months of -experimental work in perfecting the technic and controlling all factors. - -We do the original Wassermann test, using the Nogouchi antigen. All -our reagents are prepared in our laboratory and every possible control -is carried out each time the test is set up. We therefore believe that -our results will compare favorably with the best scientific work of -this character. - -At the present time a fee of $5.00 for each test is charged, containers -and instructions are supplied upon request. - -We have done the Wassermann test for the State Hospital for the Insane -at Yankton from the first. - - Mortimer Herzberg, M. D., Director. - Vermillion, S. D., February 18, 1915. - - * * * * * - -THE LOYALTY OF NURSES - - To the Editor: - -My attention has just been called to an article published in THE -JOURNAL-LANCET, August 1, 1914, it being an address by Dr. George D. -Head to the graduating class of the Asbury Hospital. The advice Dr. -Head gives to the nurses seems very good, and very elevating to our -profession, but I would like to analyze it to show that it is not quite -practical. - -It has taken considerable effort on the part of nurses to convince -the people, and to convince some doctors, that they are any more than -machines. Because we ask for three hours rest out of the twenty-four, -and because we asked for a fixed rate for service, Dr. Head says that -our loyalty to high ideals is diminishing. Unfortunately, in the -nursing profession, as in all other professions, there are some who -are incapable and unconscientious; and, if Dr. Head had the experience -of having a nurse leave a patient, unattended, at a critical time, she -probably was one of the few incapables, or was so overtired from loss -of sleep that it was necessary for her to have rest. When Dr. Head says -that a nurse should waive her rest hours for days or a week at a time, -if necessary, I think he is making a mistake. A nurse cannot do her -duty by a patient if she does not have proper rest. It is unfair to -both the patient and the nurse. Dr. Head may say that most patients are -not in need of constant attention for more than a few days or a week, -and that a nurse can stand it for that length of time without rest -hours. This is true; but we have to consider that the next case may be -just as critical, and so the nurse must reserve some strength for the -cases to follow. And more often than not, the nurse is obliged to take -cases with very little or no rest between them. - -In the second place, Dr. Head thinks that the nurses ought to have a -varying scale of charges for service. The doctors do it; why shouldn’t -the nurses? Dr. Head does not seem to consider the fact that the nurse -has one patient, while the doctor has many. Suppose a nurse takes care -of a poor patient for five or ten dollars a week, where is the rich -patient who is willing to pay forty or fifty dollars a week to make up -the loss? The nurses have found that twenty-five dollars a week is the -price that is necessary for them to live on in order to keep themselves -clothed, pay for their laundry (no small item), and carry them over the -few weeks of rest or over the dull season. The average life of a nurse, -as a nurse, is, I believe, not more than ten years. In that length of -time, at the wages she gets, she is not able to lay away a great amount -for a rainy day, which usually comes all too soon. - -We have a number of good hospitals in Minneapolis where people -in moderate circumstances can be very comfortably cared for at a -considerably less expense than employing a nurse in their homes. The -poor in our city, I think, are fairly well taken care of in the city -hospitals and by the visiting nurses, who are paid for such work. - -As for nurses refusing cases because they are afraid of them: I think -there is usually some just cause. If a nurse has a tendency towards -tuberculosis, she should refuse such cases; or if she has a tendency -towards throat troubles, she should refuse diphtheria and scarlet-fever -cases. A nurse who is constantly with a patient runs considerably more -risk of infection than the physician, whose visits are usually short. -There are nurses who make a specialty of such cases, and usually there -is no trouble finding such a nurse. Nurses who make a specialty of -obstetrical cases or of children should not take contagious work. As -for a nurse refusing a typhoid case because she is afraid of it: I -cannot believe that any real nurse would do such a thing. - -It also seems to me very ridiculous, and it surely cannot be a common -thing for a nurse to inquire before she consents to take a case whether -or not the plumbing is modern and how many servants are kept. - -As to just what Dr. Head means by saying that a nurse should be willing -to do any kind of service about a house. I do not know; but I do know -that nurses are not usually physically fit for washing or scrubbing, -yet, as a rule, nurses are glad to perform duties which are not just -in their line, in order to help the household to run smoothly. - -Most of the nurses in general work are engaged in nursing because they -are obliged to earn their living, and in most cases because they are -especially interested in this particular field; and, although most -nurses take some charity cases, it is impossible for them to take many, -even to satisfy what Dr. Head calls “the inner, higher longings of the -soul.” - - Harriet M. Prime, R. N. - - Minneapolis, February 4, 1915. - - - - -BOOK NOTICES - - - MANUAL OF OBSTETRICS. By Edward P. Davis, A. M., M. D., Professor - of Obstetrics in the Jefferson Medical College, Philadelphia. 12mo - of 463 pages, 171 illustrations. Philadelphia and London: W. B. - Saunders Company, 1914. Cloth, $2.25 net. - -As indicated by the name this is a handy book. It is well illustrated, -the text is brief and well written, and as complete as could be -expected in a work of its size. - -It presents no features which are especially new, though it takes up -many of the most recent advances in obstetrics. - -It is a work that aims to give those who wish it a concise account of -the status of obstetrics at the present time. - - --Adair. - - - BALNEO-GYMNASTIC TREATMENT OF CHRONIC DISEASES OF THE HEART. By - Prof. Dr. Theodor Schott, Bad-Nauheim. Published by Blakiston, - Philadelphia. Price, $2.50. - -This brochure sets forth in the main, preceded by a short chapter on -medical treatment, the philosophy, technic, and clinical results of -balneogymnastic therapy in chronic heart-conditions. - -It would appear, inasmuch as Prof. Schott admits the non-establishment -of the probable curative factors of either the carbon dioxide or -mineral constituents, that possibly, as Dr. Anders in the foreword -surmises, the curative properties may reside in the “advantage of being -far removed from the cares and responsibilities growing out of the -practical affairs of life at home.” - -Relative to the more firmly established value of the gymnastic -element, it is quite evident that the “resistance movements,” are an -improvement over the Zander mechanico-gymnastic, and of similar value -to the so-called “Terrain Kur,” with the added advantage of personal -application. - - --Schneider. - - - DISEASES OF BONES AND JOINTS. By Leonard W. Ely. M. D., 220 - pages, 94 illustrations. Surgery Publishing Co., N. Y. Price, - cloth. $2.00. - -Few men are better fitted than Dr. Ely to write an authoritative book -on joint and bone diseases. He has gone at his study from the only -logical end; that is, the study of the underlying pathology. The -book throughout shows the result of much conscientious work in the -pathological and x-ray laboratories, carefully checked up from the -clinical aspect. - -The average specialist who writes a manual for the use of the general -practitioner seems to think he must mention every theory which has ever -been brought out since the time of Hippocrates, together with a list -of every form of treatment ever proposed. The bewildered family doctor -gets about as much help as he would from the perusal of a few pages of -the Index Medicus. One good theory, clearly stated, even if it is not -universally accepted, may form a practical working basis which will be -of great aid to the doctor in the understanding and care of his cases. -In this particular Dr. Ely is most satisfactory. He has worked out -the pathology of the tubercular and other chronic joint diseases in -a clear and logical manner. While much may have to be altered in the -light of further research, at least one can feel sure that Dr. Ely has -convictions, and that his work will form a useful basis for further -investigations. - -The illustrations are taken almost entirely from photographs or -photomicrographs and are mostly original. So many works on Orthopedic -Surgery appear which are filled with cuts handed down from one -text-book to another, cuts of impossible people wearing impossible -appliances, that it is hard to imagine that such a book, illustrated -with such quaint old prints, can represent the latest word or offer -anything new. - -Dr. Ely’s discussion of the pathology of joint tuberculosis is perhaps -the most interesting thing in the book. His idea of the red bone marrow -and the synovia being the sole tissues to be primarily involved does -not agree with the recent work of Fraser, of Edinburgh. Evidently more -work must be done in order to harmonize these findings. - -In general, while not much space is given to treatment, what there is, -is clear and is carefully selected by the author, instead of leaving -this important point to the discretion of the reader. - -His discussion of the chronic arthritides is quite full and very -instructive. He points out particularly the resemblance between the -pathological conditions found in various chronic infectious joints and -in the various stages of joint tuberculosis. - -This little book will certainly be of use to anyone who has to treat -bone and joint diseases. - - --Reed. - - - - -NEWS ITEMS - - -Dr. Chas. Pierce, of Wadena, has moved to Menahaga. - -Dr. J. L. Stewart, of Spearfish, S. D., has located at Custer, S. D. - -Dr. Jas. Farrage, formerly of Deering, N. D., has located at Park -Rapids. - -Dr. Hugo Neukamp is leaving Fessenden, N. D., to locate in Beulah, N. D. - -The Dell Rapids Hospital was completed and opened the latter part of -February. - -Dr. H. A. Gueffroy, of Chicago, has taken over the practice of Dr. D. -F. Sullivan, of Frankfort, S. D. - -The new St. Alexius hospital, at Bismarck, N. D., was formally opened -to the public February 15th. - -The entire surplus of the old Homeopathic Hospital Association, -amounting to $1,000, was voted to the support of the Maternity -hospital, of Minneapolis, at a recent meeting. - -The Physicians’ Hospital company has been incorporated at Thief River -Falls for the purpose of building and maintaining a hospital at that -place. The company is capitalized at $25,000. - -In a previous issue we stated that Dr. G. P. Shepard, of Chicago, had -located at Jamestown, N. D. Dr. Shepard is from Courtenay, N. D., and -not from Chicago, though he has been taking postgraduate work in that -city for the past few weeks. - -The Medical Society of the State of New York invites all physicians -of the country to its hundred and ninth annual meeting which is to -be held in Buffalo, April 27-29. This will probably be the largest -medical meeting of the year, except perhaps that of the A. M. A. in San -Francisco. - -Messrs. J. D. Edgar, Arnold Hamel, R. A. Johnson, and H. A. Rudd, -and Miss Olga Hansen, all of the class of 1915, have been elected to -the Minnesota chapter of Alpha Omega Alpha, the national honorary -fraternity in medicine, the membership of which is based solely upon -scholarship. - -Dr. James E. Moore, who has practised in Minneapolis for thirty-two -years, twenty-eight of which have been devoted to the exclusive -practice of surgery, has given up his practice and will, hereafter, -give his entire time to the Medical School of the University of -Minnesota, except for a limited amount of consultation work. - -In our last issue we made the statement that the Ramsey County Medical -Society would not admit a physician to membership until he had been a -resident of the county for one year. This should have been written so -as to convey the meaning that a physician must have been a resident of -some county for at least a year, not necessarily Ramsey County. - -It is the desire of the publishers of the Journal-Lancet to make this -department of news as interesting to its readers as possible. The items -are obtained from a number of sources, and, though a great deal of -care is given to their preparation, mistakes will necessarily occur. -Will you not help to keep up the interest of this column by sending in -anything which may be of interest to the readers? Notify us of mistakes -as they occur that we may make a correction in the next issue. - -“The Mayo Foundation for Medical Education and Research, Incorporated,” -with an initial endowment fund of $1,500,000, has recently been -incorporated. It has for its object the endowment of the graduate -medical instruction and research work which has for years been a -feature of the Mayo Clinic, at Rochester. The founders are: William J. -Mayo, Charles H. Mayo, Henry S. Plummer, Edward Starr Judd and Donald -C. Balfour. The board of temporary trustees having in charge for the -present the investment of the fund is composed of Bert W. Eaton, George -W. Granger and Harry J. Harwick. The board of scientific directors is -composed of Louis B. Wilson, William F. Braasch, E. Hessel Beckman, A. -H. Sanford, and Walter D. Sheldon. For the present the expenses of the -foundation will be met by annual contributions from the Mayo Clinic, -the income from the endowment being allowed to accumulate and increase -the principal. - - * * * * * - -PHYSICIAN WANTED - -To locate in a thriving North Dakota town. For full information -correspond with Andrew Erickson, Makote, N. D. - - -OFFICE FURNITURE FOR SALE - -A good roll-top desk and other office furniture is offered for sale at -a reasonable price. 616 Syndicate Bldg., Minneapolis. - - -PRACTICE FOR SALE - -An established practice in a town of 2,000 for sale for the price of -the office outfit. If you mean business, write at once. Address 205, -care of this office. - - -SANITARIUM FOR SALE - -A new, strictly modern, 50-bed sanitarium with three acres of land on a -beautiful lake, located near the Twin Cities, for sale cheap. Address -206, care of this office. - - -WANTED - -An eye, ear, nose, and throat man who is willing to work. Must be -sober, competent man. State the salary expected, and give credentials -in the first letter. Address the C. A. Hoffman Co., 814 Nicollet Ave., -Minneapolis, Minn. - - -PRACTICE WANTED - -In Minnesota or South Dakota town, with some future and where English -is spoken. This is wanted by physician who has had several years’ -experience in practice, and has done laboratory and hospital work. -Address 198, care of this office. - - -WANTED - -A physician and surgeon to locate at Judson, North Dakota. No doctor -located within seven miles on the west and twenty-three miles or more -in other directions. One who could start small drug-store in connection -with his practice preferred. Address First State Bank, Judson, N. D. - - -WANTED TO EXCHANGE - -Contract mining practice, on Iron Range, with modern hospital, complete -equipment, autos, good roads, drive all the year, best contracts, $600 -to $800 cash each month; future very bright. Owner wishes to correspond -with an A 1 physician and surgeon with a good stand in or very near the -Twin Cities, with the view of effecting an exchange for part of the -year. Address, 204, care of this office. - - -FOR SALE - -To a man with surgical ability, one-half interest in my private -practice and well-equipped hospital, located in a live up-to-date -county-seat town in Minnesota; population 2,500; two railroads; good -schools and roads; good fees. This is an excellent opportunity to get -into a place with a good future. Price, $5,000 for one-half interest -in hospital building, equipment, office fixtures, and practice; $2,500 -cash. Don’t write unless you mean business and have the cash. Address -202 care of this office. - - * * * * * - -Doctor: If you want practical post-graduate work during the fine season -in the delightful city, write for particulars. Twenty-eighth annual -session opens September 28, 1914, and closes June 5, 1915. New Orleans -Polyclinic, P. O. Drawer 261, Post-graduate Medical Dept., Tulane -University of Louisiana. - - - - -[Illustration] - -The Battle Creek Method in Diabetes - - -Diabetes, though not always curable, is controllable. Practically all -diabetics can be made sugar-free and the acidosis disappears with the -sugar. By a special regimen the reappearance of the sugar and the -acidosis may be prevented. - -The Battle Creek method is based upon experience gained in the -treatment of many hundreds of cases supplemented by the observations -and discoveries of Von Noorden, Falta, Guelpa, Benedict, Allen, and -numerous other investigators. The essential features of the method are-- - - 1. A thorough preliminary examination and repeated examinations - comprising (a) complete quantitative examination of the urine daily, - (b) differential study of the blood, (c) chemical, microscopic and - bacteriological examination of the feces and study of the pancreatic - function, (d) X-ray examination of the stomach and intestine with - special reference to stasis. - - 2. Study of the patient’s metabolism by the respiration apparatus to - determine his respiratory quotient, CO2 tension and basal ratio. - - 3. Establishment, by the aid of metabolism studies of each case, of a - regimen adapted to the individual by determining the proper proportion - of protein, fats and carbohydrates to keep the urine free from sugar. - The kind of protein, fat and carbohydrate is considered important, as - well as the amount. - - 4. The patient’s metabolism is regulated by baths, voluntary and - automatic exercise, photo- and thermotherapy and other physiologic - means. - - 5. The results of the regimen and treatment are accurately controlled - by a “Metabolism Graphic” which shows the daily variations in the - amount of urine, amount of sugar, acidosis, coefficient of sugar - utilization, coefficient of carbohydrate utilization, nitrogen - balance, glucose nitrogen ratio, weight balance and energy balance. - These factors are all worked out by expert chemists and dietitians - and with this data before him, and a great variety of special foods - of known energy value suited to diabetics at ready command, and the - assistance of a strong corps of specially trained dietitians, the - physician is able easily to arrange a dietary adapted to each case and - to note each patient’s progress with the most careful scrutiny. - -Under this comprehensive management the sugar usually disappears from -the urine in two or three days, and does not return so long as the -prescribed regimen is followed. - -A few weeks’ treatment usually suffices to train the patient to a -suitable dietary which he may safely follow under the guidance of his -home physician. - -We will be glad to send full information concerning the Battle Creek -Method in Diabetes to any physician who will mail to us the attached -coupon. - - ..................................................................... - -The Battle Creek Sanitarium, Battle Creek, Mich. - - - Box 350 - The SANITARIUM, - Battle Creek, - Michigan - -Please send to the undersigned full information concerning the Battle -Creek method of treating diabetes. - - Dr.............................. - - Street.......................... - - City............................ - - State........................... - - - - -PUBLISHER’S DEPARTMENT - - -QUAKER OATS - -Doctors all over the country are advising the use of oat foods for the -old as well as the very young child. It is for young folks developing, -for grown-ups, who are hard workers, and for the old folks who wish to -keep young. You can safely use Quaker Oats. It costs no extra price, -and when you use it you are certainly getting the very best in oat -foods. Physicians should read their page announcement in this paper. - - -ELECTRO-THERAPY - -The Scheidel-Western X-Ray Coil Co. announce on another page that they -have the latest appliance in electro-therapeutics, namely, the Columbia -Treatment Transformer No. 9. - -The apparatus is illustrated and described on another page, and more -fully in the Company’s new catalog. - -As the Company is the largest manufacturer of x-ray apparatus in the -world, their catalog should be in the hands of every man using this -line of treatment. - - -BOREMETINE--A NEW EMETINE PREPARATION FOR PYORRHEA - -Every doctor and dentist in the United States should know about this -new preparation for the local treatment of pyorrhea alveolaris. -Boremetine is a 1-2 per cent solution of emetine hydrochloride, -together with boric acid, zinc sulphocarbolate, and aromatics. - -The emetine is amebicidal, the boric acid bactericidal, and the zinc -sulphocarbolate astringent. These three drugs meet the three essential -factors necessary for the successful treatment of pyorrhea. Boremetine -should be used in every case, either alone, or (in some severe cases) -in association with the subcutaneous injection of Emetine Hydrochloride -(Abbott). - -A special free booklet on “Pyorrhea Alveolaris: How to treat it -successfully with Emetine” will be sent on request. Send for it today. -The Abbott Alkaloidal Company, Chicago. - - -OCONOMOWOC HEALTH RESORT - -The State of Wisconsin has an enviable reputation for not a few things -in which it excels all the other western or middle-western states. -One of these is its sanatoriums, or health resorts. The climate, the -beautiful scenery, the pure water, the proximity to the large cities of -Milwaukee and Chicago, and the high-grade medical specialists made it -possible to found such institutions in southern Wisconsin long before -other parts of the middle west had the population or transportation -facilities to make success in this line either probable or possible. - -The Oconomowoc Health Resort is one of the best equipped and best -managed of these institutions. It accepts only nervous and mild mental -cases. It is under the management of Dr. Arthur W. Rogers as resident -physician. Dr. Rogers has both the professional equipment and the -personality that are necessary in the treatment and care of persons -suffering from nervous and mental disorders. - - -BATTLE CREEK SANITARIUM - -Fifty years ago examination was largely a matter of pulse finding; now -it is possible to weigh and measure the organic functions of the body -with as much accuracy as is possible in the testing of an intricate -mechanism. This becomes possible through a series of tests in many of -which elaborate equipment is required. Perhaps no other institution -has a more complete organization for diagnosis than the Battle Creek -Sanitarium. - -The physical inventory possible there is a very thorough and accurate -stock taking of the vital functions. Many business and professional men -visit the sanitarium each year in order to take full advantage of the -diagnostic facilities. - -An interesting booklet, “The Measure of a Man,” is offered free by -the sanitarium to those who care to know more regarding the system of -examination. - - -ARMOUR & COMPANY - -Why Pituitary Liquid should be specified: - -It is a pure preparation. - -It is free from objectionable chemicals. - -It is made from absolutely fresh raw glands. It does not require -preservatives. - -It is standardized physiologically. - -It is sold in dated packages, permitting the physician to discard old -goods. - -Pituitary Liquid is required in such particular classes of cases that -the practitioner can afford to use the best only. - -The use of Pituitary Liquid obviates the necessity of forceps in a -great many cases. - -Pituitary Liquid is of great service in parturition uterine -inertia--peristalic paralysis. - -We shall be pleased to send you a sample of Pituitary Liquid with -literature. - -Note the name of the perfect pituitary preparation--_Pituitary Liquid -(Armour)_. - - -THE DELICATE SCHOOL GIRL - -Even the most robust and generally healthy children show the -deleterious results of the modern system of educational “forcing” that -prevails in most of our larger cities. The child that starts the school -year in excellent physical condition, after the freedom and fresh air -of the summer vacation, in many instances, becomes nervous, fidgety, -and more or less anemic, as the term progresses, as the combined -result of mental strain and physical confinement in overheated, poorly -ventilated school-rooms. How much more likely is such a result in the -case of the delicate, high-strung, sensitively organized, adolescent -girl? It is certainly a great mistake to allow such a girl to continue -under high mental pressure, at the expense of her physical health and -well-being, and every available means should be resorted to to conserve -the vitality and prevent a nervous breakdown. Regularity of meals, -plenty of sleep, out-of-door exercise without fatigue, open windows -at night and plenty of nutritious food, should all be supplied. Just -as soon as an anemic pallor is noticeable, it is a good plan to order -Pepto-Mangan (Gude) for a week or two, or as long as necessary to bring -about an improvement in the blood state, and a restoration of color -to the skin and visible mucous membranes. This efficient hematinic is -especially serviceable in such cases, because it does not in the least -interfere with the digestion nor induce a constipated habit. - - - - -Transcriber’s Notes: - - A number of typographical errors have been corrected silently. - - The cover image was created by the transcriber and is placed in the - public domain. - - References to other pages noted in the Publisher's Department section - were not available for transcription - - The two lines below were swapped from the original: - by a chronic hypertrophic conjunctivitis. The - canthotomy necessary; and no case was followed - -*** END OF THE PROJECT GUTENBERG EBOOK THE JOURNAL-LANCET, VOL. XXXV, NO. -5, MARCH 1, 1915 *** - -Updated editions will replace the previous one--the old editions will -be renamed. - -Creating the works from print editions not protected by U.S. copyright -law means that no one owns a United States copyright in these works, -so the Foundation (and you!) can copy and distribute it in the -United States without permission and without paying copyright -royalties. Special rules, set forth in the General Terms of Use part -of this license, apply to copying and distributing Project -Gutenberg-tm electronic works to protect the PROJECT GUTENBERG-tm -concept and trademark. Project Gutenberg is a registered trademark, -and may not be used if you charge for an eBook, except by following -the terms of the trademark license, including paying royalties for use -of the Project Gutenberg trademark. If you do not charge anything for -copies of this eBook, complying with the trademark license is very -easy. You may use this eBook for nearly any purpose such as creation -of derivative works, reports, performances and research. Project -Gutenberg eBooks may be modified and printed and given away--you may -do practically ANYTHING in the United States with eBooks not protected -by U.S. copyright law. Redistribution is subject to the trademark -license, especially commercial redistribution. - -START: FULL LICENSE - -THE FULL PROJECT GUTENBERG LICENSE -PLEASE READ THIS BEFORE YOU DISTRIBUTE OR USE THIS WORK - -To protect the Project Gutenberg-tm mission of promoting the free -distribution of electronic works, by using or distributing this work -(or any other work associated in any way with the phrase "Project -Gutenberg"), you agree to comply with all the terms of the Full -Project Gutenberg-tm License available with this file or online at -www.gutenberg.org/license. - -Section 1. General Terms of Use and Redistributing Project -Gutenberg-tm electronic works - -1.A. By reading or using any part of this Project Gutenberg-tm -electronic work, you indicate that you have read, understand, agree to -and accept all the terms of this license and intellectual property -(trademark/copyright) agreement. If you do not agree to abide by all -the terms of this agreement, you must cease using and return or -destroy all copies of Project Gutenberg-tm electronic works in your -possession. If you paid a fee for obtaining a copy of or access to a -Project Gutenberg-tm electronic work and you do not agree to be bound -by the terms of this agreement, you may obtain a refund from the -person or entity to whom you paid the fee as set forth in paragraph -1.E.8. - -1.B. "Project Gutenberg" is a registered trademark. It may only be -used on or associated in any way with an electronic work by people who -agree to be bound by the terms of this agreement. There are a few -things that you can do with most Project Gutenberg-tm electronic works -even without complying with the full terms of this agreement. See -paragraph 1.C below. There are a lot of things you can do with Project -Gutenberg-tm electronic works if you follow the terms of this -agreement and help preserve free future access to Project Gutenberg-tm -electronic works. See paragraph 1.E below. - -1.C. The Project Gutenberg Literary Archive Foundation ("the -Foundation" or PGLAF), owns a compilation copyright in the collection -of Project Gutenberg-tm electronic works. Nearly all the individual -works in the collection are in the public domain in the United -States. If an individual work is unprotected by copyright law in the -United States and you are located in the United States, we do not -claim a right to prevent you from copying, distributing, performing, -displaying or creating derivative works based on the work as long as -all references to Project Gutenberg are removed. Of course, we hope -that you will support the Project Gutenberg-tm mission of promoting -free access to electronic works by freely sharing Project Gutenberg-tm -works in compliance with the terms of this agreement for keeping the -Project Gutenberg-tm name associated with the work. You can easily -comply with the terms of this agreement by keeping this work in the -same format with its attached full Project Gutenberg-tm License when -you share it without charge with others. - -1.D. The copyright laws of the place where you are located also govern -what you can do with this work. Copyright laws in most countries are -in a constant state of change. If you are outside the United States, -check the laws of your country in addition to the terms of this -agreement before downloading, copying, displaying, performing, -distributing or creating derivative works based on this work or any -other Project Gutenberg-tm work. The Foundation makes no -representations concerning the copyright status of any work in any -country other than the United States. - -1.E. Unless you have removed all references to Project Gutenberg: - -1.E.1. The following sentence, with active links to, or other -immediate access to, the full Project Gutenberg-tm License must appear -prominently whenever any copy of a Project Gutenberg-tm work (any work -on which the phrase "Project Gutenberg" appears, or with which the -phrase "Project Gutenberg" is associated) is accessed, displayed, -performed, viewed, copied or distributed: - - This eBook is for the use of anyone anywhere in the United States and - most other parts of the world at no cost and with almost no - restrictions whatsoever. You may copy it, give it away or re-use it - under the terms of the Project Gutenberg License included with this - eBook or online at www.gutenberg.org. If you are not located in the - United States, you will have to check the laws of the country where - you are located before using this eBook. - -1.E.2. If an individual Project Gutenberg-tm electronic work is -derived from texts not protected by U.S. copyright law (does not -contain a notice indicating that it is posted with permission of the -copyright holder), the work can be copied and distributed to anyone in -the United States without paying any fees or charges. If you are -redistributing or providing access to a work with the phrase "Project -Gutenberg" associated with or appearing on the work, you must comply -either with the requirements of paragraphs 1.E.1 through 1.E.7 or -obtain permission for the use of the work and the Project Gutenberg-tm -trademark as set forth in paragraphs 1.E.8 or 1.E.9. - -1.E.3. If an individual Project Gutenberg-tm electronic work is posted -with the permission of the copyright holder, your use and distribution -must comply with both paragraphs 1.E.1 through 1.E.7 and any -additional terms imposed by the copyright holder. Additional terms -will be linked to the Project Gutenberg-tm License for all works -posted with the permission of the copyright holder found at the -beginning of this work. - -1.E.4. Do not unlink or detach or remove the full Project Gutenberg-tm -License terms from this work, or any files containing a part of this -work or any other work associated with Project Gutenberg-tm. - -1.E.5. Do not copy, display, perform, distribute or redistribute this -electronic work, or any part of this electronic work, without -prominently displaying the sentence set forth in paragraph 1.E.1 with -active links or immediate access to the full terms of the Project -Gutenberg-tm License. - -1.E.6. You may convert to and distribute this work in any binary, -compressed, marked up, nonproprietary or proprietary form, including -any word processing or hypertext form. However, if you provide access -to or distribute copies of a Project Gutenberg-tm work in a format -other than "Plain Vanilla ASCII" or other format used in the official -version posted on the official Project Gutenberg-tm website -(www.gutenberg.org), you must, at no additional cost, fee or expense -to the user, provide a copy, a means of exporting a copy, or a means -of obtaining a copy upon request, of the work in its original "Plain -Vanilla ASCII" or other form. Any alternate format must include the -full Project Gutenberg-tm License as specified in paragraph 1.E.1. - -1.E.7. Do not charge a fee for access to, viewing, displaying, -performing, copying or distributing any Project Gutenberg-tm works -unless you comply with paragraph 1.E.8 or 1.E.9. - -1.E.8. You may charge a reasonable fee for copies of or providing -access to or distributing Project Gutenberg-tm electronic works -provided that: - -* You pay a royalty fee of 20% of the gross profits you derive from - the use of Project Gutenberg-tm works calculated using the method - you already use to calculate your applicable taxes. The fee is owed - to the owner of the Project Gutenberg-tm trademark, but he has - agreed to donate royalties under this paragraph to the Project - Gutenberg Literary Archive Foundation. Royalty payments must be paid - within 60 days following each date on which you prepare (or are - legally required to prepare) your periodic tax returns. Royalty - payments should be clearly marked as such and sent to the Project - Gutenberg Literary Archive Foundation at the address specified in - Section 4, "Information about donations to the Project Gutenberg - Literary Archive Foundation." - -* You provide a full refund of any money paid by a user who notifies - you in writing (or by e-mail) within 30 days of receipt that s/he - does not agree to the terms of the full Project Gutenberg-tm - License. You must require such a user to return or destroy all - copies of the works possessed in a physical medium and discontinue - all use of and all access to other copies of Project Gutenberg-tm - works. - -* You provide, in accordance with paragraph 1.F.3, a full refund of - any money paid for a work or a replacement copy, if a defect in the - electronic work is discovered and reported to you within 90 days of - receipt of the work. - -* You comply with all other terms of this agreement for free - distribution of Project Gutenberg-tm works. - -1.E.9. If you wish to charge a fee or distribute a Project -Gutenberg-tm electronic work or group of works on different terms than -are set forth in this agreement, you must obtain permission in writing -from the Project Gutenberg Literary Archive Foundation, the manager of -the Project Gutenberg-tm trademark. Contact the Foundation as set -forth in Section 3 below. - -1.F. - -1.F.1. Project Gutenberg volunteers and employees expend considerable -effort to identify, do copyright research on, transcribe and proofread -works not protected by U.S. copyright law in creating the Project -Gutenberg-tm collection. Despite these efforts, Project Gutenberg-tm -electronic works, and the medium on which they may be stored, may -contain "Defects," such as, but not limited to, incomplete, inaccurate -or corrupt data, transcription errors, a copyright or other -intellectual property infringement, a defective or damaged disk or -other medium, a computer virus, or computer codes that damage or -cannot be read by your equipment. - -1.F.2. LIMITED WARRANTY, DISCLAIMER OF DAMAGES - Except for the "Right -of Replacement or Refund" described in paragraph 1.F.3, the Project -Gutenberg Literary Archive Foundation, the owner of the Project -Gutenberg-tm trademark, and any other party distributing a Project -Gutenberg-tm electronic work under this agreement, disclaim all -liability to you for damages, costs and expenses, including legal -fees. YOU AGREE THAT YOU HAVE NO REMEDIES FOR NEGLIGENCE, STRICT -LIABILITY, BREACH OF WARRANTY OR BREACH OF CONTRACT EXCEPT THOSE -PROVIDED IN PARAGRAPH 1.F.3. YOU AGREE THAT THE FOUNDATION, THE -TRADEMARK OWNER, AND ANY DISTRIBUTOR UNDER THIS AGREEMENT WILL NOT BE -LIABLE TO YOU FOR ACTUAL, DIRECT, INDIRECT, CONSEQUENTIAL, PUNITIVE OR -INCIDENTAL DAMAGES EVEN IF YOU GIVE NOTICE OF THE POSSIBILITY OF SUCH -DAMAGE. - -1.F.3. LIMITED RIGHT OF REPLACEMENT OR REFUND - If you discover a -defect in this electronic work within 90 days of receiving it, you can -receive a refund of the money (if any) you paid for it by sending a -written explanation to the person you received the work from. If you -received the work on a physical medium, you must return the medium -with your written explanation. The person or entity that provided you -with the defective work may elect to provide a replacement copy in -lieu of a refund. If you received the work electronically, the person -or entity providing it to you may choose to give you a second -opportunity to receive the work electronically in lieu of a refund. If -the second copy is also defective, you may demand a refund in writing -without further opportunities to fix the problem. - -1.F.4. Except for the limited right of replacement or refund set forth -in paragraph 1.F.3, this work is provided to you 'AS-IS', WITH NO -OTHER WARRANTIES OF ANY KIND, EXPRESS OR IMPLIED, INCLUDING BUT NOT -LIMITED TO WARRANTIES OF MERCHANTABILITY OR FITNESS FOR ANY PURPOSE. - -1.F.5. Some states do not allow disclaimers of certain implied -warranties or the exclusion or limitation of certain types of -damages. If any disclaimer or limitation set forth in this agreement -violates the law of the state applicable to this agreement, the -agreement shall be interpreted to make the maximum disclaimer or -limitation permitted by the applicable state law. The invalidity or -unenforceability of any provision of this agreement shall not void the -remaining provisions. - -1.F.6. INDEMNITY - You agree to indemnify and hold the Foundation, the -trademark owner, any agent or employee of the Foundation, anyone -providing copies of Project Gutenberg-tm electronic works in -accordance with this agreement, and any volunteers associated with the -production, promotion and distribution of Project Gutenberg-tm -electronic works, harmless from all liability, costs and expenses, -including legal fees, that arise directly or indirectly from any of -the following which you do or cause to occur: (a) distribution of this -or any Project Gutenberg-tm work, (b) alteration, modification, or -additions or deletions to any Project Gutenberg-tm work, and (c) any -Defect you cause. - -Section 2. Information about the Mission of Project Gutenberg-tm - -Project Gutenberg-tm is synonymous with the free distribution of -electronic works in formats readable by the widest variety of -computers including obsolete, old, middle-aged and new computers. It -exists because of the efforts of hundreds of volunteers and donations -from people in all walks of life. - -Volunteers and financial support to provide volunteers with the -assistance they need are critical to reaching Project Gutenberg-tm's -goals and ensuring that the Project Gutenberg-tm collection will -remain freely available for generations to come. In 2001, the Project -Gutenberg Literary Archive Foundation was created to provide a secure -and permanent future for Project Gutenberg-tm and future -generations. To learn more about the Project Gutenberg Literary -Archive Foundation and how your efforts and donations can help, see -Sections 3 and 4 and the Foundation information page at -www.gutenberg.org - -Section 3. Information about the Project Gutenberg Literary -Archive Foundation - -The Project Gutenberg Literary Archive Foundation is a non-profit -501(c)(3) educational corporation organized under the laws of the -state of Mississippi and granted tax exempt status by the Internal -Revenue Service. The Foundation's EIN or federal tax identification -number is 64-6221541. Contributions to the Project Gutenberg Literary -Archive Foundation are tax deductible to the full extent permitted by -U.S. federal laws and your state's laws. - -The Foundation's business office is located at 809 North 1500 West, -Salt Lake City, UT 84116, (801) 596-1887. Email contact links and up -to date contact information can be found at the Foundation's website -and official page at www.gutenberg.org/contact - -Section 4. Information about Donations to the Project Gutenberg -Literary Archive Foundation - -Project Gutenberg-tm depends upon and cannot survive without -widespread public support and donations to carry out its mission of -increasing the number of public domain and licensed works that can be -freely distributed in machine-readable form accessible by the widest -array of equipment including outdated equipment. Many small donations -($1 to $5,000) are particularly important to maintaining tax exempt -status with the IRS. - -The Foundation is committed to complying with the laws regulating -charities and charitable donations in all 50 states of the United -States. Compliance requirements are not uniform and it takes a -considerable effort, much paperwork and many fees to meet and keep up -with these requirements. We do not solicit donations in locations -where we have not received written confirmation of compliance. To SEND -DONATIONS or determine the status of compliance for any particular -state visit www.gutenberg.org/donate - -While we cannot and do not solicit contributions from states where we -have not met the solicitation requirements, we know of no prohibition -against accepting unsolicited donations from donors in such states who -approach us with offers to donate. - -International donations are gratefully accepted, but we cannot make -any statements concerning tax treatment of donations received from -outside the United States. U.S. laws alone swamp our small staff. - -Please check the Project Gutenberg web pages for current donation -methods and addresses. Donations are accepted in a number of other -ways including checks, online payments and credit card donations. To -donate, please visit: www.gutenberg.org/donate - -Section 5. General Information About Project Gutenberg-tm electronic works - -Professor Michael S. Hart was the originator of the Project -Gutenberg-tm concept of a library of electronic works that could be -freely shared with anyone. For forty years, he produced and -distributed Project Gutenberg-tm eBooks with only a loose network of -volunteer support. - -Project Gutenberg-tm eBooks are often created from several printed -editions, all of which are confirmed as not protected by copyright in -the U.S. unless a copyright notice is included. Thus, we do not -necessarily keep eBooks in compliance with any particular paper -edition. - -Most people start at our website which has the main PG search -facility: www.gutenberg.org - -This website includes information about Project Gutenberg-tm, -including how to make donations to the Project Gutenberg Literary -Archive Foundation, how to help produce our new eBooks, and how to -subscribe to our email newsletter to hear about new eBooks. |