values to those which the after-period showed corresponded to the diet did not occur in the course of an experiment which lasted for a week. A sweeping out of the acetone bodies would adequately explain the results in case 3, but in case 2 no increased excretion was noted in a subject brought into equilibrium with a diet until alkali was given, and it is difficult, in spite of the fact that normal values were found thereafter, to believe that the results were wholly due to a sweeping out of these substances. Only two explanations of the findings in case 4 seem possible; either there was an increased production of the acetone bodies brought about by the small amounts of alkali used, or else experimental errors invalidate the results altogether. The results found on subject 5 are more in accord with the increased production of the acetone bodies than with the other hypothesis, but the findings cannot be considered as convincing. CONCLUSION Increases were found in the excretion of the acetone bodies by subjects at or near the border-line of ketosis when small amounts of sodium bicarbonate were added to the diet. There was apparently an increased production of the acetone bodies and also a sweeping out of acetone bodies already produced which could be demonstrated under suitable experimental conditions. Changes in volume of urine were not responsible for these findings, and both fractions studiedone from preformed acetone plus acetoacetic acid and one from B-hydrotybutyric acid-showed the changes. REFERENCES ALLEN, F. M., STILLMAN, E., AND FITZ, R.: Total dietary regulation in the treatment of diabetes mellitus. Monograph 11, Rock. Inst. Med. Res., New York, 1919. BRYANT, A. P., AND ATWATER, W. O.: The chemical composition of American food materials. Bulletin 28, U. S. Department of Agriculture, Washington, 1906. CLARKE, H.: Clifton Medical Bulletin, 1924, x, 22. FORSSNER, G.: Skand. Arch. Physiol., 1911, xxv, 338. HALDANE, J. B. S.: Abstracts of Com munications to the XI International Physiological Congress held at Edinborough, July 23 to 27, 1923. HUBBARD, R. S.: Jour. Biol. Chem., 1921, xlix, 357. HUBBARD, R. S.: Jour. Biol. Chem., 1923, lv, 357. HUBBARD, R. S., and Wright, F. R.: Jour. Joslin, E. P.: Jour. Med. Res., 1904, xii, 433. JOSLIN, E. P.: The treatment of diabetes mellitus. 2nd edition. Philadelphia and New York, 1917. MOSENTHAL, H. O., KILLIAN, J. A., AND MYERS, V. C.: Proc. Soc. Clinical investigations, Washington, May, 1922. Abstracted in Jour. Amer. Med. Assoc., 1922, 1xxviii, 1751. MOSENTHAL, H. O., AND KILLIAN, J. A.: Proc. Amer. Soc. Biol. Chem., Toronto, December, 1922. Abstracted in Jour. Biol. Chem., 1923, lv, xliii. WIDMARK, E. M. P.: Biochem. Jour., 1920, xiv, 364. The Borderland Between Neurology and N General Medicine BY GIVEN CAMPBELL, St. Louis, Missouri EUROLOGY is a diagnostic clearing house. Until quite recently many physicians on meeting a medical condition, or group of symptoms that was ill-defined, and difficult of diagnosis, felt that it must be of nervous origin, and it was customary to send such cases to the neurologist. It devolved on him to find out what the condition really was. Many cases of alleged neurasthenia proved to be incipient tuberculosis or commencing hyperthyroidism. An occasional case of intercostal neuralgia proved to be aneurism of the arch of the aorta, or was due to a cervical rib or some condition of the bony spine, belonging to the orthopedic surgeon. Many cases of indigestion, supposed to be nervous in origin, proved to be caused by some structural disease in the gastro-intestinal tract. Although, in the writer's opinion, the converse more frequently holds true. As the various specialties have been more generally recognized, many of these cases no longer pass first through the hands of the neurologist. It was when neurology was the land of medical mystery that these things occurred. This mantle of Elijah has fallen on the new prophet of medical advance, and the modern Elisha's name is endocrinology. Endocrinology itself forms no small part of this borderland. One, however, in which many isolated facts have been acquired but not enough coherent knowledge, the writer believes, to make our notions of the subject clinically very usable. With the exception of what we know of the thyroid and of some of the very definite effects of supra-renal extract and pituitrin, our knowledge of the internal secretions and their effect on life processes is too vague and their effects too much intermingled for us to use these facts as yet, very intelligently. Perhaps the most important borderland between neurology and general medicine consists in the early recognition of paresis, for it is not with the neurologist that the paretic first comes in contact. The beginning symptoms of this dread disease are so insidious that they are often for many months not recognized by the patient's family and still less by himself as a disease. It is necessary that the doctor who is thrown in contact with such patients be ready to recognize changes in behavior, often very intangible, before his attention is formally called to them. If the family medical adviser and friend is on the alert for the symptoms I shall speak of in a few moments, he will not infrequently recognize the condition in time to prevent the family fortune being swept aside before the breadwinner himself is subjected to long illnesses, with institutional care and with an ending in death. We should remember that the patient in his forties (the usual time of onset of paresis), is too old for the manic depressive states, or dementia praecox, to first manifest themselves; he is usually too young for the involutionary changes in his nervous system to progress far enough to produce mental changes even of a very indefinite type. The signs to be looked for are at first so intangible that they are often not recognized as mental at all. It is well known that the parts of us of the most recent developmental acquirement are the least stable. The nerve mechanisms involved in self control; conscience, character, in short, anything that constitutes the true man as differing from the cruder types, is first to suffer. Such a one will often forget the little niceties, finer points of ethics and morality, and these lapses will be attributed to innate depravity, but do not forget that these, although little, are very important lapses. They really do not commence during the forties without some serious reason, and a careful examination of pupils, tremors, knee jerks, facial innervation, blood and spinal fluid, especially the cell count, Wassermann and globulin, will usually clear up the situation while there is time, and save the patient's accumulated money (in his forties he is at his best earning power and in the midst of his most important business activities), and the writer believes, also, that if taken at this time, there will be an occasional case in which the course of the paresis can be permanently arrested, and while the man may remain at a somewhat lower intellectual level, he will be able to continue earning his living during the rest of his life. Another aspect of nervous syphilis that offers an extensive borderline is seen in the many manifestations of tabes; this especially applies to the crises. The sharp colic-like pain in the upper abdomen, with a sensitiveness of the skin over that region, and the characteristic zonal paraesthesia, closely resembling gall bladder disease, and yet mark the condition as tabetic. One need only mention the atonic bladder with paroxysmal feelings of distress in that region, which accompany tabes, but nevertheless need genito-urinary treatment; the rectal crises and the laryngeal crises with sudden spasmodic coughing and strangling spells at times. I have seen and reported one case, there being but one other on record, of what might be called a thermic crisis in tabes, in which there seemed to be paroxysmal disturbance of the heat-regulating centers. The patient gave a history of a number of previous attacks and was seen in one in which without any apparent cause, with a not particularly accelerated pulse, nor a disturbed blood count, nor much in the way of malaise, the temperature went up to 109 and remained at this point for several hours. The patient was feeling entirely well the next day, and in the writer's opinion, his tabes was the only thing that could account for his temperature rise. An early recognition of the lightning pains of tabes is important both in that they are frequently mistaken for rheumatism, and that they often occur long before any other tabetic symptom; so that if through their aid tabes is recognized sufficiently early, mercury or perhaps salvarsan with spinal fluid drainage offers a more than even chance of permanently arresting the tabetic condition and saving the individual to usefulness through the rest of a long life. Where the tabetic pains have to be considered later in the disease so that treatment cannot remove their cause, the writer would like to mention as a means of relief the use of aluminum chloride in doses of from 2 to 8 grains three times a day, after meals, largely diluted, as a rather specific remedy for this condition. Its use was first noticed as being recommended by Gowers in a paper on general therapeutic optimism. The writer tried it in his service at the City Hospital some years ago, not having much faith in its benefit. The pains, however, got well under its use. Knowing the transient nature of the pains, he was inclined to attribute their departure to accident rather than to the medicine. On one of his visits some weeks later, he found that the patients felt they had gained so much relief that (the hospital having no further supplies) they themselves had sent out and bought the medicine with their own money and were using it and giving it to others suffering from these pains. This suggested that the medicine might be of benefit after all. Its use was carefully checked and the results reported and the writer feels sure that under its employment, we have a definite remedy against this element of tabes; but against this element only; it does not help the disease. It does not help the visceral crises, but its use in combating the lightning pains will frequently render unnecessary the employment of habit-forming drugs where the pain without it would be so severe as to render morphine necessary. To mention one of the most difficult problems for solution where the work of the internist and the neurologist joins, we have but to speak of the relationship between hyperthyroidism, incipient tuberculosis, and a general run-down state due perhaps to nervous exhaustion, some latent infection or auto-intoxication. It is probably true that one of the early accompaniments of a tuberculous infection is a stimulation of the thyroid to increased activity. activity. The frequent pulse, the slight rise of temperature, the loss of weight can be present with either condition, but I have observed and reported before the American Neurological Association a pulse sign that I think is somewhat helpful in differentiating between a pulse frequent because of hyperthyroidism on the one hand, and that in which the frequency is due to the toxemia of tuberculosis or to a generally run-down condition on the other. It is this: That a pulse frequent because of hyperthyroidism does not increase so much as ten beats when the patient changes from a sitting to a standing posture, while with all other usual conditions known to the writer, where the pulse is unduly frequent, the difference between the rate when sitting and when standing is more than ten beats. It has been said by Dr. Ludwig Braemer, formerly a resident of St. Louis, and much of a medical philosopher, that there were but two classes of doctors; the generalists and the peripheralists. He said that the generalists could be divided into two groups, one being the internists and the other the neurologists. The followers of the various other specialties were what he called peripheralists, that is to say they see the condition from which the patient suffered more clearly than they do the patient suffering from that condition. And in the disentangling of the problems mentioned just above, a generalized view of the entire patient is the only one that will help us toward a correct solution of his troubles, and here I believe the neurologist is more of a generalist than is the internist, for not only do physical conditions, thyroid tests, the effects of iodine, tuberculin reactions, and physical signs play their part as far as the bodily condition of the patient is concerned, but also the psychic life of the individual must be estimated in all of its complex bearings. I believe there are many such borderland situations where estimating the patient's entire life processes, both bodily and psychic, will prevent disease conditions from becoming definitely fixed as such. I have much modified my opinion as to the importance of a little albumin, a few casts, or of a rising blood pressure in middle aged people. I feel sure these conditions can come and go as the wear and tear of life is modified in the patient, and until changes very definitely structural have occurred in the kidneys or blood vessels, I believe, by a proper regulation of life conditions entirely non-medical in their nature, as well as by removing causes of focal infection, that the evidences of kidney or blood vessel disease can be made to disappear and remain permanently in abeyance during many years. It has been said that the pathologist is like the man who goes around on the fifth of July and by examining the pasteboard cases of the skyrockets tries to tell us about what had occurred in those containers when the living explosive material sent those rockets well up into the heavens. In other words, the intimate, vital processes of life are so different from the terminal processes the pathologist sees, that the physician who forms his opinions from what he finds on the autopsy table is apt to take a too pessimistic view of commencing disease conditions. Migraine is another subject that covers a borderland extending into the domain of the rhinologist as well as of the general practitioner. The neurologist is inclined to consider that the innate, hereditary thing we call migraine is probably due to an essential difference in the make-up, or response of the brain cortex; built into this cortex as a part of its architecture. The internist looks on the migrainous individual as one with so-called deficient elimination, or as belonging to the neuro-arthritic type, as classified by the French. It is highly probable that this definitely hereditary condition when present, marks an individual as being more subject to the early involutionary changes in his vaso-cardio-renal system than is the ordinary individual. It is also certain that if migraine be so interpreted, and if each individual be made to follow a regime which combats these changes, that his vital expectancy can be increased. There appear to be certain headaches some of which very much follow the type of migraine, which are due to disturbances set up by the nasal ganglion. The writer's viewpoint is that the nasal ganglion is probably the pathway through which migraine produces |