THE LOUISVILLE MEETING. Another annual session of the Kentucky State Medical Association has come and gone. In many respects this was probably the most successful meeting we have ever held. The attendance was a little larger; the program was a little better; the interest in the work of the organization was some more pronounced; the commercial exhibit was unusually good; politics was conspicuous by its absence; and the demonstrations in obstetrics and fractures were wonderfully successful, thanks to the labors of Drs. Speidel and Murphy.

In the election of the president, after the nominations had been made, it would have been difficult to have made a mistake. Dr. A. M. Vance, who was elected, is one of the most distinguished surgeons in the whole country. Aside from this, he has always been interested in civic and professional betterment. More than any other man, he is responsible for the splendidly equipped and built new City Hospital in Louisville. His distinguished career insures for the Association an officer of the highest order during his incumb

ency.

Drs. Anderson of Newport and Stewart of Paducah were the contending candidates. The services of either of them to medical organization merited the honor to which their friends aspired for them, and the JOURNA.. predicts their early recognition by the Association.

The next issue of the JOURNAL will contain the minutes of the House of Delegates and a number of papers of such importance that the various county societies will be requested to hold special meetings to consider them. Medico-legal matters have assumed such an angle that it is essential that every doctor in the State know about developments for his protection. The State Association is ready and willing to do for the doctors of the State all it can, but it is essential that we remem

No. 11

ber always that it is composed of twentyfour hundred active men and each of them must do his share to co-ordinate and make its work effective.

REMEMBER YOUR FRIENDS.

Of all the medical journals in the United States there is one editor who from time to time says things so incisively and so well that it is a pleasure to quote him under the above caption. In the August, 1915, California State Journal of Medicine Dr. Jones gives utterance to some sentences which should animate every reader of this JOURNAL and every thoughtful physician in Kentucky.

There was a time, not so many years ago, when no respectable publication would refer to its advertisements or its advertisers. To be sure, many items boosting advertised things appeared in some periodicals--mostly medical (?) journals-but these were what is known as of the "reading notice" variety; carefully prepared by the advertiser and furnished to the publication; they were run as part of the advertising obligation. Now, however, and largely through the influence of your own Journal, all that has changed; we are proud

of advertisers and our advertising. Nothing goes into the advertising pages that is not as carefully scrutinized as the matter that goes into the reading pages. A considerable amount of advertising is refused each year because the Journal cannot vouch for the statements or the standing of the wouldbe advertiser, or for several other reasons. There is no reason, now, why any advertiser should not be referred to or anything advertised should not be mentioned in any part of the Journal. And please remember that these advertisers are your friends; they very materially help out the business of the Society by so liberally patronizing the advertising pages of your Journal. They offer, for your consideration, a constantly changing variety of things that it would pay you to take an interest in; there is always something new com

ing along, and it will be well worth your while to see, from month to month, what new things are set forth in the advertising pages. You can save money, you can learn a lot that will be of benefit to you, and not infrequently you can secure samples or catalogues or premiums that are of real value. Also, just remember that there is no "bunk" about any thing we advertise; if you are not entirely satisfied with your transactions with any advertiser, the Journal stands ready to straighten out the matter. The new things in this The new things in this issue are too numerous to mention right here. but just look them up and see for yourself; if you have not looked through the advertising pages for a couple of months, it will surprise and please you to see the number and variety of new things and new suggestions set forth. The statements made and the information contained in our advertisements may be absolutely relied upon. Help your friends and those who help you. Read the advertisements in this issue."

SOME COMMON MISTAKES.

We desire to call to the attention of the readers of the JOURNAL a very important communication from Dr. Franz H. Harms, Pathologist of the National Pathological Laboratory in Chicago, in a recent issue of the Journal of the Missouri State Medical Association on "Some Common Mistakes in the Interpretation of Laboratory Reports." In view of the long standing card carried by this laboratory in our columns it has secured a considerable patronage and it is classed with the Louisville Research Laboratory and others of the most reliable in the country. It will be of interest to every physician who patronizes these Laboratories to remember the important errors to which Dr. Harms calls attention:

"There is a tendency to diagnose a nephritis ipso facto when the laboratory findings show the presence of albumin, and the severity of the condition is gaged by the percentage of albumin present. The object of this article is to emphasize the errors in these hasty conclusions.

"It is necessary at the outset to exclude false or accidental albuminuria due to admixture of the albuminous exudate, blood or lymph through the urinary tract, by examination microscopically of the sediment and also by consideration of the clinical picture. After a false or accidental albuminuria has been excluded, there are still the renal albuminurias without anatomic lesions of the kidneys which must be ruled out. These are classified by Saxe as: (1) functional albuminuria: (a) after severe muscular exertion, (b) after eating an excess of proteid food. (e) following nervous shock and other vasomotor changes,

(d) during labor, (e) in nervous children; (2) essential albuminuria: (a) cyclic, (b) orthostatic or postural, (c) albuminuria minima (Lerocche and Talamom) after infections or debilitating diseases; (3) traumatic albuminuria, slight injury to kidney, massage of kidney, movable kidney, injury to brain, apoplexy; (4) hematogenous albuminuria, such as severe anemia, purpura, scurvy, cholemia, diabetes, leukemia, severe wasting discases and after anesthetics; (5) nervous albuminuria, insanity, mental depression, psychoses, paralysis of certain parts of brain, epilepsy, delirium tremens; (6) albuminuria of renal stasis in conditions of passive congestion; cardial, pulmonary and hepatic discases in the presence of mechanical pressure (stones, tumors) may occur with casts and usually a few red blood cells; (7) toxic albuminuria, irritants. (cantharides turpentine), poisoning with arsenic, mercury, phosphorus, lead, antimony, alcohol, mineral acids, febrile diseases.

"In many of these functional disturbances casts may be found.

"Only when these are ruled out and when the urine shows albumin and casts repeatedly and there are clinical symptoms as well, can a positive diagnosis of nephritis be made.

"The amount of albumin varies usually with the type of disease. In acute cases it is large in amount, becoming variable as it becomes chronic and small in amount in severe cases of contracted kidney. Exceptionally, however, the amount may be large when there is no kidney lesion at all, as in passive congestion, and on the other hand, albumin may be entirely absent at times in interstitial nephritis."

THE PROFIT AND LOSS ACCOUNT OF MODERN MEDICINE.

Under the above title one of the most delightful and readable collection of papers by an American author has just been published by Dr. Stewart McGuire of Richmond, Virginia. Everyone who knows McGuire admires and loves him, and every physician who reads this collection from his versatile writings will find that he has gained one of the profits of modern medicine. While many of the papers are surgical, they are written in a style that is so interesting and on a scope so broad that everybody will be interested in what he has to say. To one who comes in contact with medical publications frequently, it seems a pity that there are not more books published which show the originality, the genius, and the interest of this small one. L. H. Jenkins, of Richmond, Virginia, is the publisher, and copies may be ordered directly from him.

SCIENTIFIC EDITORIALS.

GASTRIC PHYSIOLOGY AND THE BITTER TONICS.

I am constrained to believe that one of the most important of recent communications has been somewhat overlooked by editorial commentators, a contribution to the pharmacological knowledge of the bitter tonics in their action upon the human stomach. This article not alone adds directly to our sum total of knowledge, but upsets some of the well-rooted lay and medical ideas. A. J. Carlson, assisted by Miss Torchiani and Mr. Hallock contribute an article to the Journal of the American Medical Association, No. xxi under the caption of "Physiology of the Stomach" and sub-caption, the "Supposed Action of the Bitter Tonies on Secretion of Gastric Juice in Man and Dog" Vol. lxiv., No 1, Jan. 2. 1915, p. 15), which, I think, not alone important 'from its own standpoint, but believe the results may be amplified and extended to other fields, comment upon which will be made in this writing. Speaking conventionally, all of us are or were in the habit of giving "tonic appetizers," that is to say, a bitter tonic, little realizing its actual futility or stopping to realize the far greater "appetizers" we have in other measures other than those fetishes, medicinal measures. Some day, I hope to present a psychological analysis of that medical narrowness characterized by the inability to realize therapy from any other than a chemical, pharmacologic or medicinal standpoint, but this large contract will have to be passed to some future time, pigeonholed temporarily with many other items waiting patiently for attention. In order that we may more clearly understand the work done and the results achieved, I abstract from this paper the following:

"The so-called stomachics or bitter tonics acting in the stomach alone have no appreciable influence on the hunger mechanism when given in the usual therapeutic quantities. If the stomachics are taken by mouth in the ordinary way, all of them inhibit gastric tonus and hunger contractions in direct proportion to the intensity and duration of stimulation of the nerve endings in the mouth. If the bitters are introduced directly into the stomach in quantities considerably in excess of the therapeutic dose they all cause inhibition of the gastric tonus and hunger mechanism, evidently by stimulation of nerve endings in the gastric mucosa. In brief, the bitIn brief, the bitter tonics, in so far as they influence the hunger mechanism directly, cause inhibition or depression of hunger. According to Heubner and Reider, large doses of bitters also re

tard the emptying of the stomach (dog). This must be due to a direct depression of the gastric movements of digestion, or to a retardation of the digestion process itself.

"It seems pretty well established that the bitters have no action on the pepsin-hydrochloric acid digestion itself, except possibly in way of slight retardation. This slight retarding action is of no practical significance, especially when the bitters are taken twenty or thirty minutes before the meal, or even just before the meal, because of the great dilution with gastric juice, saliva, and the fluids of the food. The literature also points to the conclusion that by themselves the bitter tonics are incapable of causing secretion of gastric juice either by acting in the mouth or in the stomach. Pawlow, noted in dogs that the bitters acting in the mouth cause a copious flow of saliva, but leave the gastric gland perfectly quiescent; and not even when introduced into the stomach do they cause secretion of gastric juice.

"It will be recalled that Mr. V., our man with permanent gastric fistula, has the esophagus completely constricted at the level of the upper end of the sternum, so that nothing can be swallowed from the mouth and reach the stomach via the esophagus. Above the constriction the esophagus is somewhat dilated so as to hold about half a glass of liquid. These conditions serve admirably for studying the influence of the bitters on the secretion of gastric juice.

"On all test days 100 c.c. of water were put into the stomach 120 and sixty minutes before the meal, so as to insure a completely empty stomach. The tonics were introduced into the stomach via the fistula between fifteen and thirty minutes before the meal time. In the series of tests with the tonics in the mouth, these were put into the mouth and swallowed into the esophagus pouch ten minutes before the meal.

"The experiments were made during the months of April to November, 1914. The tests with the tonics were interspersed with controls without the tonics all the way, so as to eliminate as far as possible the errors from variations in nutrition, appetite, etc., associated with variations in climate and bodily activity.

"It was aimed to make these tests a mere incident to Mr. V.'s daily routine. For that reason no special dietary standard was fixed. The ingredients of the noonday meal Mr. V. selected for himself at a nearby cafateria. He naturally selected what appeared to him most palatable from day to day. The evening meal was taken in the same boarding house throughout the experimental period. Mr. V. states that the boarding house meals are very

much the same from week to week, and less palatable than the noonday meal.

"The tonics used (in therapeutic doses) were tinctures of gentian, quassia, calumba, humulus and condurango, and elixir of quinin, strychnin and iron. Most of the tests were made with the gentian tincture and with the elixir.

"In order to exclude all possible psychic factors, Mr. V. was not told of the purpose of the experiments. He went about his daily work, taking his usual food at the usual time, while now and then a tonic was given and the appetite secretion measured. I think it may be safely concluded that such psychic factors as knowledge of and faith in the remedies were carefully excluded in these tests.

"As Mr. V. is a young man in good health, the question naturally arises whether the sensory nerves for the appetite sense (in mouth and stomach) are not normally in a state of maximum excitability, so that no further increase in excitability by bitter tonics is possible. This objection seems to be met by the lower secretion at the evening meal. Here is a condition in which less palatable food should have been rendered more palatable by contrast with the bitter tonic, or by actual increase in the excitability of the gustatory nerves. The results indicate no improvement by contrast. If the bitters in the mouth augmented the excitability of the taste nerves at the evening meal, this evidently caused an already unpalatable food to taste still more unpalatable, and hence the diminished appetite secretion.

"These bitters in mouth or stomach produced no change in the acidity and in the pepsin concentration of the appetite gastric juice.

"The annual experiments were performed on five dogs and may be summarized as follows: namely, that these bitters acting in the mouth or in the stomach have no effect on the secretion of gastric juice in the dog, nor did they influence or produce any changes in acidity or pepsin concentration. But as regards any favorable action of these stomachics on the gastric secretory mechanism in man and dog. our results go to show that it is nil, at least when all purely psychic factors are eliminated.

"The use of bitters as medicine goes back so far that there is no authentic record of its beginning, and the number of different kinds. of bitters advocated from time to time as useful is a large one. They are of so varied chemical composition that the only thing they have in common is the bitter taste. Of course, in this discussion, we do not include such substances as quinin or strychnin, or the bitters with alcohol as the main constituent, as these substances have distinct physiologie actions

not directly related to appetite after absorption into the blood.

"The bitter tonies are still common 'home remedies' and favorite 'drug-counter prescriptions'. They are often prescribed as a matter of routine and sometimes ordered because the physician actually believes they produce good results. Is this belief well founded? These tonics are given to convalescents who would continue to improve, tonic or no tonic, and the tonic, not the recuperative power of the patient gets the credit. For many ailments the physician prescribes a more hygienic living and a tonic. The patient's health improves and both physician and patient think the tonic did it.

'But even if the bitters have no direct action on gastric secretion and digestion, and no appreciable indirect action on the secretion of gastric juice, may they not be valuable aids in expelling worry and in implanting hope and good cheer in the mind of the patient? May they not be an efficient handmaid to psychotherapy? According to Cushny that is their main, if not their only value. There is no question that the bitter tonics connect up with the popular belief that the potency of a medicine is directly related to its strong (or bad) taste. And the readiness with which these tonics are dispensed by the physician nourishes the popular superstition that there is, or must be, a specific drug remedy for every ailment, a superstition that constitutes the open sesame of the medical quack and the patent medicine vender.

"The stimulation of certain nerve endings in the mouth and in the normal gastric mucosa unquestionably contributes to the complex sensation of appetite, and these nerves are stimulated by condiments and flavors of food. Apart from this, the physiological way of augmenting hunger and appetite is moderation in the food intake or increasing the utilization of the food in the body work and cold. If these measures do not improve, the chances are that the digestive tract is not in a condition to take care of the amount of food demanded by the stronger hunger and appetite sensations.

"To be sure, in therapeutic doses these tonies may be harmless, except in so far as their use contributes to the drug habit in emphasizing the 'take something' instead of the 'do something.'

"The prescription of bitter tonics is a fetish, a survival of the days of ignorance, of savagery and should be abandoned. Why they are ordered, or they are ordered, or what they really accomplish for the person who takes them, has usually either been answered in only the vaguest terms, overlooked entirely by teachers of therapeutics. Nor must it ever be forgotten that appetite and hunger are by no

or

means identical sensations. The relation of bitters to the sensation of hunger is amenable to experimental investigation in view of the now established facts in relation to the

genesis of the latter. The hunger sensation is evidently produced by certain types of contraction of the empty stomach. These can be recorded accurately. Hunger pangs are absent so long as the empty stomach is relatively atonic and quiescent.

"When quantities sufficiently large to produce a demonstrable effect are introduced, the action is always in the direction of inhibition. Introduced into the mouth, the action of the stomachies and bitters is like that of all sapid substances. They stimulate the taste organs and nerves of general sensation in the mouth, and cause reflex inhibition of the gastric hunger contractions. It will thus be seen that the bitters have no effect whatever in the way of augmenting hunger contractions and the attendant sensations. It seems settled that neither the hunger sensation nor the gastric secretory mechanism is affected in the way that many have been led to suppose.'

Let us say at the outset that we not only are heartily in accord with Carlson's work, but after long clinical observation and study, we have for years observed, the increase of the food intake, with appetite and hunger. where the three above noted factors entered into the physiological equation.

In health we all over cat; as a rule when chronically (not meaning incurably) sick we eat too little. It is to be noted that if there is a relatively lessened intake this is more likely to be utilized, that is to say digested, absorbed, entering inte anabolic and katabolic processes, more thoroughly oxidized and better eliminated. Where physiological processes of nutrition are normally and thoroughly performed the individual not only is in better nutritional balance, but is less likely to be sick owing to the establishment of that tangible yet intangible force, vital strength; is more capable for daily work and better balanced physically and psychically. Where there is the greater demand that comes with real, normal, healthy appetite and hunger, there are more active gastric movements, quicker solution, because of normal juice and acidity, digestion is more rapidly performed, there is less residue, and hence quicker empty

ing, or emptying within the normal period. "Well begun is half done" is an old adage that applies with unusual force in this instance. It means normal nutritional balance, with neither increase or decrease of weight, relish and enjoyment of food, good bodily strength, an evenness of mental work and better temper, (save in some notable exceptions).

(b). Bodily work, labor or exercise is not only a constant factor, but the last named is constantly prescribed by the physician, often wrongly so, based usually on the "lay" idea, not upon that strict scientific basis that should be the medical guiding star. The results of proper exercise are as a rule easily observable, hence the frequent and sometimes ill advised suggestion, “You must exercise," for it takes judgment to come to the decision, and all cases are not alike, nor does one patient need as much exercise as another. It is said that J. Pierpont Morgan was at one time breaking rapidly until some discerning physician told him never to exercise, but to take his airings in his motor. He promptly recovered. Increased bodily activity produces katabolic or destructive activities, increased oxidation and the necessity of prompt elimination. elimination. If this latter is weak we must guard these organs from excessive strain by rest. As soon as the katabolic changes are well established there is an increased demand for food, better appetite and hunger, with later anabolic or reconstructive activity, for bodily activity increases function, secretion, excretion and all metabolic processes. Labor, as well as an inanimate machine when active, demands more fuel. Where this is heavy and performed in cold regions great demands are made for food. Commander Peary, in his account of his last Polar expedition makes the statement that living upon the pemmican and heavy food during the dash and return made the lighter food of the ship seem very phantom-like and unsatisfying, and that he had gradually to return to the ship's food. It seemed "thin." Here again, we find, is the explanation of the action of massage and vi bration which possess such unusual value for the sick, because they possess nearly all the advantages of exercise to the patient without the expenditure of any energy from his meagre store.

(c). That cold is normally a producer of appetite and hunger is a daily observation. Let us be prostrated by a severe hot spell for several days. have sudden and delightful change to cooler weather and in a short time we are all ready for a gastronomic attack. We know that cold weather produces a "bracing" effect due to the oxidizing properties of cold which are absent in warm and hot weather. Here we see again the same influ