antipyretic, an inhibiter of reflexes, a protoplasmic poison, a vascular sedative and having the great advantage of being rapidly diffused and slowly excreted, the profession would go wild over it and would use it for a host of common affections. And yet quinine is all of that, and is just as valuable as it ever was. Why don't we use it more? Take our word for it, we should not forget quinine. Uterine Curettement. BY EXPERIMENT upon the uterus of a dead animal, we have entirely satisfied ourselves that no uterine curettement can accomplish what the surgeon designs it to do except in the following instances: removal of portions of uterine tissue or content for diagnostic purposes, removal of placental debris, and the removal of por tions of abnormal endometrium. The first use admits of no discussion; the wisdom of removing placental debris by means of the curette cannot be determined off hand, each case depending upon the circumstances; while surgeons differ as to curettement of the abnormal endometrium, although it is quite generally agreed that sepsis of the endometrium generally contraindicates curettement. Formerly the curette was used in the treatment of a host of conditions, but there is growing objection to its use, and with this objection we heartily sympathize, having done curettement with unsatisfactory results more frequently than with benefit to the patient. A study of the anatomy of the uterine fundus will soon convince any physician that, the endometrium being composed largely of lymphoid tissue instead of true mucosa and with no protecting submucosa between it and the myometrium, Nature never intended instruments to be inserted within the womb. We believe we do so with more or less peril to the woman. A curettement may extend a pre-existing infection; the curette may perforate the uterine wall; it may even injure the abdom inal contents through a perforation; it may induce peritonitis; it may carry in infection from without; it may induce dangerous hemorrhage; finally, it may initiate chronic uterine diseases and sterility. So far as we are personally concerned, we have not used the curette in the delivery of retained secundines since 1895, and had occasion to be sorry we did then. The finger is the best curette we know, and the only really safe one. So far as endometritis is involved, it is rare at best. Most so-called cases are not really endometritis at all. Gonorrhea and tuberculosis cause most of the real cases, and what good the curette can accomplish in the treatment of these conditions we confess we cannot see. The Medical Preceptor. THIS WORTHY seems to be quite out of date. We believe he should be revived. The editor spent a year and a half with a preceptor before entering medical college, and practiced with him during the summer vacations. And the time was well spent. During that eighteen months we read through nearly the whole range of books, including the U. S. Dispensatory. Also we put up nearly 3,000 prescriptions. of the good old type, saw many hundreds. of patients largely upon our own responsibility, did considerable minor surgery and attended obstetrical cases. As we look back upon it we shiver for the people we attended, and yet no disasters occurred. We had more assurance and nerve before entering medical college than we have ever possessed since. And when we did matriculate and took up study, what an advantage all that experience had been. Medicine appeared the most orderly of sciences. We could see the clinical connection of all we were taught, and the whole sequence of things unrolled in beauty and order. We took several laboratory electives and advanced courses, and how they did illuminate what was learned at the bedside. Naturally the preceptored students gravitated together, and graduation day showed this little coterie at the head of the class. They were not a bit brighter than were the other students, but they understood things as they went along. Later experience has served to confirm our view favoring the preceptor. Despite all his advantages the modern medical student is little if any help to the established doctor wishing to be relieved from many details. We dare not trust the student of to-day except in our laboratory work: he may do that better than we do ourselves. And even the recent graduate has to be shown a host of little things he should know without telling. We admire recent methods wherever they accomplish results, but more and more is the conviction forced upon us that a period with a good preceptor would be worth more to the student than an additional fifth year in the school. Direct Local Treatment of the Lung. Τ WO FRENCH physicians, Guisez and Stodel, are developing a method of a direct endobronchial and intrapulmonary injections of healing and antiseptic medicaments, and it is quite possible that the lung parenchyma may be so tolerant of introduced oils that the method will mark a most positive advance in respiratory therapy. It appears that the sensitive area which must be obtunded is not the lung itself, but the root of the tongue and the larynx; and this area is first anesthetized with cocaine solution. After proper local anesthesia of these parts, a long canula is used to inject two c.c. of a one to forty (1:40) novocain solution into the trachea. A trace of adrenalin may be added to the novocain solution. All manipulations are done with the guidance of the laryngoscopic mirror. It requires about four minutes to anesthetize the trachea, and then fifteen to twenty c.c. of medicated oil is introduced into the trachea through the canula. Various medicaments have been tried, but one to twenty (1:20) of guaiacol appears to be highly useful and the most readily tolerated. After one learns the technic, patients experience very little inconvenience, and but a small amount of the oil is lost by coughing. The injections may be given alternate days until the patient becomes tolerant, when daily treatment may be undertaken. The method is not, as yet, fully developed, and more detailed technic is not available to us. The most favorable clinical results have been in cases of pulmonary gangrene, tracheal diseases, bronchial dilatation and bronchopulmonary infections. Cases reported are most encouraging as promise of future development and utility of this very rational procedure. The Action of Vanadium. There appears to be no very great clarity of view as regards the action of vanadium. From our reading of the subject, the following data appears to be fairly well justified: we secured it from various sources, largely the researches of Jackson. Vanadium, in toxic doses, acts upon the kidneys and alimentary tract like the irritating metals generally. Intravenously its chief action is upon the vascular system, although not through the nervous mechanism, and the phenomenon of cutaneous and muscle tissue vessels dilating seems to be due to visceral displacement of the blood from vasoconstriction of the vessels of the spleen, kidneys and intestines. Theoretically vanadium should prove of value in internal hemorrhages of these organs. Like iron, vanadium possesses tonic effects in the opinion of many, and also like iron, no one knows exactly why it is tonic. Vanadium is an instance of a whole lot of "new" remedies. Whenever we strike a brand new one in therapeutics we dig up old homeopathic literature, and it is surprising how frequently we find it described. From a homeopathic materia medica published in San Francisco, in 1903, we quote the following: "Vanadium (the metal). A remedy in degenerative conditions of the liver and arteries: tuberculosis, anemia, chronic rheumatism, diabetes. Acts as a tonic in digestive function and in early tu berculosis. Dose.-The best form is vanadiate of soda, 2 mg. daily, by mouth." We have no doubt vanadium is a good thing, but it certainly is not new. Colles' Law and the Wassermann This old law is to the effect that a woman who has borne a syphilitic child may herself become immune to the disease. The Wassermann reaction is partially dependent upon the employment of substance derived from the liver of a syphilitic fetus. We have speculated somewhat upon these two factors and wonder if it might be possible to establish an artificial immunity against syphilis by injecting into the healthy individual a properly prepared vaccine or serum derived from the blood or tissues of a syphilitic fetus. Perhaps it is but "a midsummer night's dream"-only it is a good one to have come true. Bronchitis in Old Persons. One often observes a winter bronchitis in old persons, which is characterized by a tenacious, yellow expectoration, leaving the patient exhausted and faint after attacks of coughing. We want to commend two remedies which have done excellent service in our hands; fluidextract of eucalyptus, and hydrastis. The eucalyptus is very hard to combine with other agents, but we have found the syrupy malt preparations to carry both eucalyptus and hydrastis. We give 5 to 8 minims f. e. eucalyptus, and 10 to 20 minims colorless hydrastis in a dessertspoonful dose of the malt preparation. THERAPEUTIC NOTES. Oil of juniper is a valuable diuretic in the treatment of renal lithiasis. It is surprising how much good a systemic tonic will do in many nasal diseases. Children with catarrhal pneumonia are very apt to be debilitated by purgatives. Better use suppositories or enema. Look out for that case of Pott's disease not definitely tuberculosis. Late-occurring Pott's disease is very apt to be of syphilitic origin. Hexamethylenamine, in 10 grain doses dissolved in a glass of water and taken four times daily, is recommended as useful in breaking up a cold. Swayne, in a study of acidosis, among other conclusions, states that the administration of chloroform is contraindicated in this condition, especially in an eclamptic woman. In case of catarrh of the Eustachian tube and middle ear, do not inflate or allow the patient to inflate more than two or three times a day. Frequent or forcible inflation aggravates the condition. Again has iodine demonstrated its usefulness; its 10 per cent. solution in glycerin being highly useful as an application to the pustules of small-pox, drying the lesions and preventing extensive pitting. The pure powder of sodium salicylate can be very freely applied to boils, and some authorities claim that rather free scarification around a carbuncle, and to which the salicylate is applied, rubbing into the scarifications, will shorten many cases. After cutting out the white spots of follicular tonsillitis with hydrogen peroxide, use a gargle of a saturated solution sodium phenolsulphonate. Another good gargle is made by pouring boiling water upon sulphur and quicklime and, after the reaction is completed, using a dilution of the clear solution in such strength as may be tolerated. R. W. Wilcox has devised a very useful remedy for chronic bronchitis. It is as follows: Ammonium chloride and extract licorice, of each one-half ounce; fluidextract eucalyptus, 1 ounce; syrup yerba santa, to make 4 ounces. In a case with free secretion the ammonium chloride can be omitted. Eucalpytus is especially valuable in this condition. Original Articles The following articles have been written exclusively to the editor and readers of this journal. Other journals republishing any of these articles will, as a matter of professional courtesy, kindly give credit as follows:-Medical Council, Philadelphia. We are not responsible for the views expressed by contributors. Sentences, like sunbeams, burn deepest when most condensed. Management of Pneumonia. By DELANCEY ROCHESTER, M.D., In order to treat any acute disease scientifically so that we can do our best to put the patient in such condition that he will recover, we must understand two things thoroughly, viz., the modes of death in those cases which do not recover and the modes of recovery in favorable cases. With such knowledge we can bend our energies towards preventing the development of those conditions favoring the first and towards aiding them in the development of those conditions favoring the second. Death in pneumonia occurs either from intensity of toxemia, failure of the heart or some complication: recovery takes place by crisis, accompanied by profuse sweat and sometimes by marked diarrhea. The most serious complications of pneumonia are meningitis, pericarditis, empyema and nephritis. The indications for treatment in pneumonia are, as has been well said by one of our English confreres, "to make the blood clean and keep it going around," and to prevent, if possible, the development of serious complication. We must recognize that pneumonia is primarily a general disease, a blood infection, with local expression in the lung, the kidneys, the liver and the heart, and that it tends to recovery within two weeks, generally in seven to ten days. Elimination. Nature has pointed out to us that in this disease the chief avenues of getting rid of the poisons are the skin and the bowel, so we should follow nature's indication by stimulating these organs to activity. For purposes of stimulating the skin we have recourse to the hot mustard foot bath, scientifically administered in bed. The method in which this is administered is of great importance and is as follows: the patient in a nude state lies between blankets, the foot-tub half-filled with hot mustard water is introduced into the bed, its long axis being in the long axis of the patient; a blanket is so placed beneath the tub that it may be brought up over it and over the knees of the patient whose feet with the knees flexed are in the tub; then another blanket and a third are placed over the patient and the tub and coming up to the patient's neck: an ice cap is kept constantly on the patient's head while he is in the bath; more hot water is added from time to time by the nurse who should always put her hand into the water in the tub and, in pouring in the hot water, she should be careful that it strikes the side of the tub and is well stirred in, so that it may not burn the patient's feet. A foot bath given in this way generally produces prompt sweating. It should be kept up fifteen to forty-five minutes, according to the amount of sweat produced. These baths may be given every four to six hours. At the same time the other great avenue for getting rid of poisons should be called upon. For this purpose an initial dose of 5 or 10 grains of calomel should be administered, followed in six hours by solution of Epsom salts. of Epsom salts. The calomel may be repeated two or three times, either alone or combined with jalap, and followed by the salts. Stimulating diuretics should not be used, as the kidney is itself involved in morbid changes, but alkaline drinks are very useful in helping to render the urine non-irritating, and so also in aiding to get rid of some poisons in this way. Diet and Air Supply. While attempting to get rid of toxins by these means, it is important to put and keep the patient in the best possible condition to resist and overcome the toxemia that is present. For this purpose care should be exercised in the selection of a proper diet. This should be fluid and so far as possible should be sterile, so that no new poisons may be introduced. A large amount of pure water should be administered so that there may be plenty of fluid to flush the excretory organs. It is best administered in small amounts at short intervals. At the same time the patient should be so placed that he receives the fullest amount of fresh, pure air possible. Sometimes, where there is much involvement of lung, thus cutting down the available surface for oxygen absorption, the administration of pure oxygen by inhalation is of undoubted benefit. Venesection. When, in spite of all these efforts, the toxemia remains marked, as indicated by persistently high temperature, increased frequency of pulse and respiration, the development of tremulousness, subsultus tendinum, delirium and a coated dry tongue, a turn for the better and ultimate recovery may be brought about by the prompt withdrawal of eight to twelve ounces of blood and the introduction, by hypodermoclysis, of a little less amount of normal salt solution. Sometimes it is of more value to keep the bleeding up over a prolonged period. This can be done by the application of leeches, six or eight in number, over the chest or over the edge of the liver. I have bled many patients in this way and have never seen any evil results from the bleeding, and have often seen such prompt and decided improvement that I have no hesitation in urging the procedure in suitable cases. The value of this procedure is well illustrated by the following case: M. R., female, colored, aged 18; entered the hospital April 19, 1909, having been sick three days. Examination revealed pneumonia involving the lower lobe of each lung, accompanied by marked pleurisy on the left side. Leucocytes 22,050; 89 per cent. polymorphonuclear neutrophiles. Temperature 106 F., pulse 110, respiration 40, coated tongue, foul mouth; subsultus tendinum; delirium of the low, muttering type and great restlessness. In spite of the usual treatment she grew steadily worse, so that, on April 26, the sixth day of disease, the temperature was 106 F., pulse 150, small, and somewhat tense; respiration 46. The urine showed an increasing albuminuria and she was becoming stupid. At 5.15 P. M. she was bled 200 cc. Improvement began immediately. In five hours her temperature was 102 F., pulse 110, respiration 30. In thirty-six hours her temperature was 98, pulse 90, respiration 24. She went on to uninterrupted recovery. The change in the picture from that of impending death to that of mild febrile sickness in five hours was most instructive as to the value of the procedure. I have bled for this purpose in fifteen cases, always with benefit and in most cases with recovery. In one very toxic case I bled three times, with final complete recovery. There is one word of warning which I wish to give here, and that is: do not bleed even in very toxic cases if improvement, even though slight, has begun. I had two sad experiences earlier in my career, in that the bleeding under those circumstances was followed by an increase in toxic symptoms, and in one case death ensued in forty-eight hours. The object of the bleeding under the circumstances related above, is to get rid of a considerable amount of toxic material and may sometimes be followed with benefit by hypodermoclysis of normal salt solution. In the two cases in which I bled after slight improvement had begun, I believe I removed blood in which antibodics had begun to form in sufficient quantity to win the battle, and I removed them. Sustaining the Circulation. By the adoption of the above measures we meet the first indication of treatment, viz., to make the blood clean. The second indication, to keep the blood going round, is partly met by these same procedures as, by these means, more blood is kept moving in the peripheral vessels and there is less tendency to collection of blood in the deep venous channels and the right side of the heart. This can be further helped by the regular administration of strychnine in full doses (gr. 1/30 to 1/20 hypodermically at two to four-hour intervals). Other remedies of avail in this disease to meet this indication are aromatic spirits of ammonia, ammonium carbonate, camphor, caffein, infusion of digitalis and sometimes digitalin hypodermically or strophanthin intravenously. Bleeding is useful also as a means of keeping the blood in circulation when the right side of the heart becomes so dilated that it cannot contract effectively and empty itself. This shows itself by increasing cyanosis, increasing dyspnoea, edema of the lungs, enlargement of the liver, and fullness of the veins of the neck, and the evidence of dilated heart by physical signs. The beneficial results of the removal of blood by venesection are, if possible, more striking in these cases than in those previously referred to, as is well illustrated by the following case: A boy, aged 17, had a severe attack of migratory pneumonia, in which each lobe of both lungs and the pericardium were successively attacked, the crisis finally occurring on the nineteenth day with recovery. At one time in the course of the attack I was called in a hurry by the nurse, and found that for two hours he had been growing decidedly worse. His temperature was 104 F., his respiration 66, and his pulse 180, small and irregular; he was cyanotic and suffering greatly from airhunger. At that time there was hepatization of the entire right lung and upper part of the upper lobe of the left lung. The heart, by physical examination, showed apex in anterior axillary line in sixth interspace; the right border could not be marked on account of consolidation of right lung, which was so completely solidified that I |