Exercise in moderation is to be recommended; and even when the joints of the leg are affected a certain amount of walking should be allowed; but this should not be sufficient to cause lasting pain. Even when the patient can only get about in a wheeled chair, fresh air is desirable; for it must be our aim in this, as in other matters to keep the patient in as good a state of general health as possible. II. Climatic Treatment.-A warm, dry climate and a dry soil are the most suitable to rheumatoid patients, and the climate should be as equable as possible, as sudden fluctuations are apt to increase their pain. If the patient's home is in a damp neighborhood, removal to a drier locality should be urged; and well-to-do sufferers often obtain benefit from wintering in a warmer climate than this section of the country affords. In the choice of a place of sojourn, the importance of an equable warmth` should be borne in mind. Such a change is specially adapted to cases in which the disease is not sufficiently advanced to cripple the patient; for when this stage is reached, the discomforts of a long journey may counterbalance the good to be expected from a change of climate. III. Treatment by Baths.-Patients suffering from rheumatoid arthritis constitute a large proportion of the frequenters of spas; and there can be no doubt that the external application of medicated mud and mineral waters is often beneficial, especially as an adjunct to medicinal treatment. In almost all cases in which circumstances permit, the patient, in whom the disease is not already so far advanced as to preclude hope of material advantage, should be advised to undergo a course of thermal treatment in addition to other measures; and it may be advisable that the course should be repeated annually for several years. On the other hand, this form of treatment may be overdone; it has appeared to me that a short course is often of more ben efit than a long one, and that the good derived from a first visit is sometimes imperilled or annulled by too early a repeti tion of it. Peat or mud baths, such as I am using at Mudlavia, are of undoubted value as hundreds of people who have been greatly benefited by our treatment, can testify. I am fully convinced that the mud baths are more beneficial than hot mineral water baths. Vapor baths often give marked relief for the moment, and by reducing pain and stiff ness, frequently improve the patient's powers of locomotion considerably. cess. The electrical treatment of arthritis deformans has been carried out on two distinct lines, and in both ways with some sucThe older mode was by direct application to the affected joints and their neighborhood, by using the continuous current, and so setting up vasomotor changes to modify the nutrition of the joints. The more recent treatment consist in general electrification by means of the electric bath, in the hope of changing the general state of nutrition of the whole system, and so, indirectly, of arresting the morbid process. bonate, arsenic, iron, especially the syrup IV. Of Drugs, I have found guaiacol carof iodide of iron, and, in some cases, potassium iodide, to be of the most value. General tonic treatment is indicated of course. To correct the acid fermentation and imsodoxylin, or the following: 2 gm. (30 grs.) prove the motor function of the stomach of sodium bicarbonate, 0.6 gm. (10 grs.) of potassium bicarbonate, and 1 gm. or 1.3 gm. (15 to 30 grs). of aromatic chalk in a glass of milk, given about half an hour before meals, and a double dose at bedtime; often smaller doses suffice. An excellent stomachic which may be needed in some cases, is calcium chloride, hydrochloride acid, and minute doses of the tincture chloride of iron to be given after meals. A small cholagogue pill should be regularly administered to keep the bowels open; for this purpose an excellent mixture can be made with the sulphate bicarbonate, salicylate of sodium and licorice. The pancreas is also usually at fault, and to improve its action a capsule of holadin and bile salts may be given about two hours after meals. In these cases the thyroid gland is usually too active, and so, save in gouty or luetic cases, all preparations of iodine and thy roid should be avoided. Possibly suprarenal gland and pituitary extract might do good, as it has been shown that these secretions tend to retain the lime in the system, whereas the thyroid increases its elimination, but it is preferable not to prescribe such powerful drugs when milder ones may suffice. It is imperative to get lime into the tissues and to lessen its elimination, but herein lies our difficulty, as no matter how much is administered by the mouth, it may be as rapidly excreted as it is absorbed, and so none may reach the tissues; but on the other hand the acidosis in the blood may be taking lime from the tissues as well as from the intestinal tract. In order to get the lime into the tissues there must be a liberal oral supply, and the blood must be kept very alkaline. For this it is well to prescribe freely chloride of sodium and potassium, sodium bicarbonate, chalk, lactate of lime, and calcium glycerophosphates. If it be desired to get calcium rapidly into the tissues it may be given in a very dilute form subcutaneously, say 1 litre (1 pint) of sterile normal saline solution with 0.05 per cent of calcium chloride, and 3 per cent of syrup of glucose. If the calcium chloride be administered hypodermically in a concentrated form, it may readily produce gangrene of the skin and adjacent tissues. Iron is best administered in the form of underdoue red meat and yolk of eggs. Guaiacol not only relieves pain, but, if taken long enough and in sufficient quantities, is capable in some cases of arresting the course of the disease, decreasing the size of the joint and allowing increased movement. Both in the subacute and the chronic forms it is useful, its action being, probably, to arrest further infection from the intestinal tract, and, after absorption, to combine with the bacterial toxins and thus assist the removal of the hypertrophied fibrous tissue. The most convenient form in which to give this drug is that of the carbonate in cachet, this salt being a white powder which is free from the disagreeable odor, taste and stomach-irritating effects of the plain guaiacol. It becomes slowly split up into guaiacol and carbon dioxide in the intestines. From .3 to .6 gm. (5 to 10 grs.) of the guaiacol carbonate should be given three times a day at first. This should be increased .06 or .12 gm. (1 to 2 grs.) each week until the dose reaches 1 to 1.3 gm. (15 to 20 grs.). That this treatment be continued for at least a year is essential. The effects of guaiacol may be greatly aided by the simultaneous administration of a mixture containing potassium iodide, whose depressing effects may be counteracted by combining with it the triple arsenates of iron, quinine, and strychnine with nuclein. Arsenic given in small doses for three weeks out of every four is valuable. Arsenic stimulates gastric and intestinal digestion, thus increasing the appetite, while it heightens the activity of the tissues, favoring assimilation of food. Also it improves the condition of the blood by causing an increase of red marrow in the bone. I have used cacodylate of sodium hypodermically with good results. The effects of medicinal treatment, as of other measures, are most marked in the cases in which the disease appears in early life and in its more acute form; but the patient should be instructed to persevere in any line of treatment, even if at first there be no obvious improvement, or indeed the reverse; for it is a common experience that even in the cases in which the most satisfactory results are ultimately obtained, no effect is apparent for several months after treatment is commenced. V. Vaccine Treatment by means of autogenous vaccines in case a focus of infection can be found, should be practiced. It is not always possible to locate any focus, but the mouth, throat, ears, genito-urinary tract, should all be carefully examined and any trouble in these localities relieved if possible. I agree with Billings who says: "The treatment and management must comprise: (a) the removal of the cause; (b) improvement of the immunity by rest, personal hygiene, good food, pure air, and sunshine, rational calisthenics and physical culture, moral support and a cheerful environment. Autogenous vaccination may be used to improve immunity still further." If the source of infection is discovered, and if an autogenous vaccine can be made, it should be employed by all means. A. Bertram Soltan reports experiments with vaccines derived from staphylococcus A. He claims that the employment of this vaccine has been followed by marked improvement. The dosage has been from 150,000 to 3,000,000 or 4,000,000. It has not always been easy to prevent excessive reaction, and at times a reversion to the earlier minute doses has been necessitated after reaching the highest doses mentioned. The reaction has usually been an exacerbation of joint pains and swelling, together with slight rise of temperature. The injections are usually made at weekly intervals. VI. Local Treatment. In rheumatoid arthritis local treatment is of little avail; even when it is applied for the relief of pain, the results are usually disappointing, and it has no influence upon the course of the malady. Continued dry massage, as distinguished from a short course of douche-massage, has the advantage of restoring the wasted muscles; but it is not of any material benefit to the affected joints, and if too long continued, sometimes seems to do harm rather than good. For the relief of pain anodyne liniments of belladonna, chloroform, and the like may be applied; or an old prescription, originating with Haygarth, who first described the clinical features of the disease, may be tried, namely, covering the painful joints with hot sand. The joints may be wrapped in cotton wool, or woollen knee-caps may give relief. Splints are to be avoided as far as possible; but when, as is seldom the case, they seem to be required, they should be constructed of cardboard, or of some other material which affords some support without altogether preventing the movement of the parts. ELIXIR CINCHONAE, N. F. ELIXIR OF CINCHONA; PERUVIAN CORDIAL; ELIXIR OF CALISAYA.* A. N. DOERSCHUK, Kansas City, Mo. The usual preparation of elixir calisaya seen in drug stores, unless freshly made, presents a very unsightly opaqueness and precipitate, and is far from being the delicate and inviting bitter tonic vehicle intended by the physician when he orders this item. The National Formulary process is bad and not well studied. It has always been undesirable to make tinctures from fluid extracts and it is more so to try to make elixirs from tinctures. Proctor's formula of sixty years ago made a much more delectable preparation. This consisted of percolating cinchona bark and aromatics with brandy and water and adding sugar. The sample herewith has stood for over a year without filtration, and was made as follows: Into a clean gallon bottle place 1850 grains of cinchona in number 60 powder previously triturated with one ounce purified talc, and add 42 ounces of alcohol. Agitate occasionally during three days, and then add 690 minims of glycerine, and 16 ounces of distilled water. At this point the alcohol has dissolved the resins and coloring matter of the cinchona much more completely than an alcoholic dilution can do, and by the addition of the glycerine and water, the cinchona is now suspended in the correct menstruum for the tincture with the added solvent benefit of all the alcohol in the aromatic elixir as well. The volume of solvent now acting on the cinchona is around 60 ounces while the finished tincture used to the gallon is only 19 ounces and 80 minims. By occasionally agitating this mixture well corked on a slow warm water bath for two hours, all the active principles of the cinchona come; into solution. Add Abstract of a paper read before the Missouri State Pharmaceutical Association, June. 1915. This specimen shown won first prize for best N. F. product exhibited. 442 minims compound spirit of orange, 16 fluid ounces glycerine, 38 troy ounces of sugar, and agitate. The sugar being introduced at this time aids in preventing much precipitation when warm water is added sufficient to make one gallon. This mixture should stand some days, and before filtering should be well chilled in the refrigerator and filtered cold. By this means are eliminated the extractives that come down in changing weather and make this preparation usually so unsightly. After the filter is started add five ounces of water to the mixture in the bottle to make up for the displacement of the powders. The product will filter out one gallon, and if the complete first filtrate is agitated and again passed cold through the filter, a very handsome product results that stands up well and has the full value, color, brilliancy and aroma elixir calisaya should have. 432 Westport Avenue. It STRICTURE OF THE URETHRA.* HENRY H. MORTON, M. D., Brooklyn, N. Y. In making a diagnosis of stricture we cannot tell anything from the history. simply tells us that the man has an obstruction in his urethra which may be stone, prostate, or stricture. The diagnosis is made by examination, and the flexible bulbous bougie is the best instrument for this purpose. A steel sound is too inexact, as the sound passes through the stricture, gradually dilating it, whereas, a bulbous bougie, on being withdrawn, catches on the stricture band, and a sensation as if passing over a fiddle string is felt. All soft and recent strictures are treated by dilation and many organized strictures may be treated in this way. For dilation two instrument are used: 1, sounds. 2, dilators. The effects of dilation are that mechanical stretching and small tears take place in the substance of the stricture, under the mucous membrane, blood supply is increased and absorption is favored. By repeated dilations the character of the tissue is changed from a live scar, which would contract, to a dead scar, which has little or no tendency to contract. In all cases begin with sounds, using one large enough to just stretch the stricture. Massage of the urethra over the sound gives beneficial effects of massage as well as dila *Abstract of clinical lecture given in the Long Island College Hospital. tion. Sounds should be passed about once a week. After a full sized sound no longer dilates the stricture we use a dilator, increasing one or two points at each sitting, followed by an irrigation with silver nitrate 1-4000. Severe bleeding means too much dilation and patient should have two weeks rest. False passages are made by pushing the end of sound into the periurethral tissues. In very tight strictures a filiform guide should be passed and a tunneled sound threaded over it and passed into bladder. If stricture is so tight no sound can be passed, the guide may be left in for 24 hours causing superficial ulceration, then a flexible bougie is passed and left in for 24 hours. This is continued, using a larger bougie each time till a sound can be passed. This method is not in common use today. False passage, or in very tight, heavy, dense, tortuous strictures immediate external urethrotomy is indicated. Correspondence CHILDREN OF LIGHT.* Editor Medical Herald: Recent criticisms on an article in the "New Republic," entitled "The Control of Births," contains flagrant misconceptions of the function of sex power. I wish to restate the problem in some of its vital aspects. Many claim that there is but one object for sexual intercourse - the creation of healthy human beings. I claim that men and women who have brought only physical children into the world as the fruit of sexual power are barren of the supremest gift of life. Sexual union is not only a miracle in its reproductive function, but in its psychical dynamics as well. It may and should mean spiritual transfusion, an exchange of psychic currents, a rehabilitation of the whole nervous organism, a soul bath of creative ecstasy, which shall bring forth children of light to fertilize the dreary wastes of life. *The writer of this beautiful classic on pure sexuality is not a physician. She is a womanly woman, the mother of three children of whom the youngest has just completed the high school course. She is a busy woman, actively editing a strong; independent daily newspaper; is active in social duties, is a fluent and much sought speaker, a careful and noteworthy housewife. In her public addresses, she invariably incorporates direct reference to sexuality, skillfully balancing her lesson that it may provoke thought without repelling those-the majority-not yet emancipated from the shackles of prudery. The thoughts of a pure, womanly woman of intellectual potency, on this vital question, give a different viewpoint from the plain scientific deductions of any man, and hence are of particular value to the professional reader. G.H.B. Out of the spiritual resiliency induced by perfect mating is woven the stuff of which dreams are made, art, music, poetry, noble deeds; radiant creative energy are intimations of its passional splendor transmuting even the sordid and commonplace into more gracious form. That this relationship means "only lust" as our critics aver, if the reproductive function is controlled, is to ignore utterly the whole complex range of subtle vibrations which fuse two kindred souls in perfect union, reacting later in an afterglow of creative energy which far transcends the capacities of their separate selves. In what it does to those worthily partaking of this sacrament through its châstening tenderness, its appealing sweetness and divine compassionateness, its incomparable rapture, its far reaches of human comradeship, its consecration to noble heroism, and its sustaining power to bless and humanize only those who surrender their lusts and passions, and are purged and purified through its consummation can divine. Out of the fullness of such joy, the reticence of one who knows, may with impunity be brushed aside that the truth may set us free for only as we voluntarily create these values and project them into daily living, will the children of light be born and the miracle unfold in all its glory. There is splendid justification for sexual union apart from child bearing, for those whose spiritual kinship fertilizes the world with joy and light. But for those on the primitive plan who can bear only fleshly offspring (although I doubt if many are barred from some adumbrations of divine ecstasy) the gate of paradise is barred as by a flaming sword. We are just on the threshold of understanding what proper knowledge, control, and conservation of sex power may mean, but we know this much, that lavish expenditure of this power through wayward abandonment is wasteful and pernicious that a false valuation of sex functions, a distorted conception of their dignity and worth in the scheme of life are insidious deterrents to its full beneficence and react with baleful effect to pervert and vulgarize the supreme miracle of nature. We need very much to transvalue our current sexual values to prophylacticize the whole sex relationship with scientific clarity and sanity, to restate the functional possibilities of such union in terms of life itself, not narrowed to human offspring that we need to rescue this ever-recurring miracle from its low grovelling instincts and transient satisfactions, gilding it with all the splendor of our creative powers, that it may bloom in evermore wondrous beauty unto the enrichment of our common life from whose elemental hungers it has sprung. Physical union may bring forth children of the flesh, but only a spiritual union will bear children of light, and we need both to fertilize the world. A WOMAN, Song Sermons G. HENRI BOGART, M. D., Paris, Ill. THE HUNTSMAN. Brown October, like brown ale, Not for food want; for pulsing thrill When brown quail are whist'ling Dun November, chill and drear, Mark points in the game. Rich, red sumac and walnut's gold, In rustling heaps. Again they'll grow, Himself, Life's best game. The French and the Belgians have a saying, "Scratch a German and find a pig,' an opinion which under present circumstances they will probably hold more firmly than ever; a thought that is a half sensed glimmer of the universal truth, that we are the children of our parents, that the primal caveman stands ready to burst through the veneer which we have come to know as civilization, and oh, so few realize just how thin is that glossy, shining surface, under which we hide the real selves, that are the Us. The lads in olden Sparta found their dinners tied to the branches of trees, where they had to win the food by the slingstone or arrow; a turning back to the slightly earlier time when the skill of the huntsman was his sole market, when life was pitted against life that the survivor live. Today is exactly the same, life is pitted against life, whether it be the clinging vine or gorgeous orchid of the tropics, drawing sustenance from the tree that bears them, or the man and woman in the industrial fields of our complex civilization. The child eating its supper of bread and milk is consuming the vital forces of the farmer who sweated in sowing and reaping, as well as of the placid-eyed cow, who surrendered her bossy baby, that her udder yield food for those others. Everywhere we are cannibals, devouring the life work of others, who in turn eat from our production, the fruition of our living. All of living is the recurrence of the olden rule "A life for a life," not in the narrow meaning as a law for punishment, but in its wide ethical significance. The true huntsman, the sportsman in clean, sharp definition, does not seek the wild things of wood and water for satisfaction of appetite, nor yet for the mere cruel lust of blood, he responds to the welling call of his forebears, he pits his skill and mentality against that of his quarry, that he may bring home a well-filled tag at eventide. The life span is an endless game, a contest, and when the final sunset draws nigh, the successful one is himself the fruit of the chase in the manhood that is his. You doctor, are giving your life for others, and they in return are giving their sweat and their energy to support you, they are giving life for life, illustrating the sometimes puzzling text, "Whoso would save his life shall lose it." All the time the best there is in us is that we are losing our lives for those others," thereby gaining the most for ourselves. A royal family has Ich Dien-I serve-for its motto; the crown of existence is strong, earnest, effective service. Gross used to say there was a power of life saving in huge doses of tincture of iron not manifested by any other known remedy. He was right too. It is becoming recognized among the members of the medical profession that semi-invalids are usually given too much time for introspection and that if useful, interesting occupation is provided, their symptoms really become less acute. In line with this healthful theory, the Battle Creek Sanitarium has instituted an occupational school in which many of the patients have already interested themselves their health betterment. Many useful branches are taught in this school, including weaving, basketry, stenciling, clay-modeling and others. The efficacy of the project, especially in quieting nervous patients, has been clearly demonstrated. to ! |