prescritpions which they do not wish refilled with out their permission. And the written instructions, limited to reasonable cases genuinely calling for prohibition, will be scrupulously respected, thereby bringing about a universal and satisfac tory solution to the entire vexed question.

We cordially indorse and commend the sugges. tion of the National Retail Druggists. As inti mated at the outset of this editorial, we realize the dangerous possibilities attending the indiscriminate practice of refilling prescriptions sheerly upon the patient's say so; yet we are not in sympathy with those extremists who would enforce just as indiscriminate a prohibition against the refilling of all prescriptions. We, therefore, regard the proposition of the Druggists' Association as a timely and sensible one. Here, at least, is a point upon which the retail druggists and the physicians may get together in the interests of all concerned, and bring about a satisfactory solution to what is at present a vexed and chaotic situation.

́ ́EMBALMED” TEACHINGS IN MEDICINE

It is all right, of course, for medical science to be conservative; to be exceedingly cautious about abandoning time-honored and proven theories and practices, which have done good service for many years, for new and comparatively untried doctrines. That is perfectly proper in a science and a profession which concern themselves with human life and health. But we think this principle of conservation hardly goes far enough to justify the embalming of defunct teachings and practices and parading the petrified mummies through the procession of the text books from year to year as though they formed an actual contingent of modern medicine. Mummies are very interesting, to be sure; but their place is in a museum, not in a living procession. Yet this is precisely what is done in the standard text books of surgery, which, as we have intimated in another editorial, are as a rule considerably ahead of those on internal medicine. The pages of almost all the standard text books are loaded down with dead material-obsolete forms of treatment long since abandoned by progressive practitioners and in many cases known to be utterly valueless.

Only a month or two ago, for instance, a distinguished Chicago gynecologist-one of the comparatively few real gynecologists-in a most sensible article, exposed the dead-and-buried fallacy of the glycerine tampon which is still being exploited in the text books. This local procedure is almost universally recommended by the books, and employed by many of the readers of the books, although, as the gynecologist in question shrewdly points out, not by the writers of the

books. Yet it is not only an obsolete form of treatment, quite out of step with our modern conceptions of gynecological pathology and therapeutics, but is a mischievous practice, productive in almost every case of chronic invalidism, both from chemical and mechanical causes.

The bromides are still gravely paraded in neurological text books as the sine qua non of the treatment of epilepsy, although every practicing neurologist knows that they are not only practically valueless to stop the seizures, but in every instance induce a condition of chronic bromism. which makes the last state of that patient worse than the first. The painting of a furunculus with tincture of iodine is still recommended as a routine abortive procedure. We should like to hear from some practitioner who has ever been able to prevent the maturing of a boil by this means. Large doses of potassium iodide still form the stock text-book treatment of several respiratory and circulatory diseases, including asthma, myocarditis, cerebral hemorrhage, and arteriosclerosis; but we have yet to see or hear of a single case of any of these diseases where the iodides accomplished any other result than to upset the digestion and bring out a rash.

These are but a few common and conspicuous examples of the thing we are criticising. Why are these dead-and-gone obsessions still given a place in current medical teaching? Why are they not rather given a decent, respectful interment among the archives of the past and allowed to rest in peace? If it were simply a question of overloading the text books and either wasting good paper and ink, or else crowding out more vital stuff, that would be bad enough. But, unfortunately, they mislead the younger and less sophisticated practitioners, who are obliged to learn by tiresome, and sometimes costly, experience which are the living truths and which are mummies. And meanwhile the public suffers. Small wonder the Christian Scientists and other healing cults flourish. Let us, so to speak, have a medical housecleaning, and resolutely gather together and throw out, as we are obliged to do in our homes sometimes, all the old, useless truck that has been accumulating on our shelves and in our closets. which we have been fondly preserving, partly from a sentimental unwillingness to part with the old things, and partly from a foolish notionwhich we know is foolish all the time we are entertaining it—that it may come in useful some day.

"Miss Ann Teek has had her house furnished in colonial style."

"Well, she ought to feel thoroughly at home amid such surroundings."

"Pneumonitis," as its nomenclature signifies, is an inflammation of the lungs. In a descriptive sense, it is an acute sthenic or asthenic fever, attended by an exudate, "croupous" or "catarrhal" in character, to the vesicles, bronchioles and parenchyma of the lungs, with a "natural" tendency to terminate in a distinct "crisis." The subtitles under which its pathology and treatment are studied are "croupous pneumonitis," named from the character of its exudate, and "catarrhal bronchopneumonitis," named from the constituent of its exudate and the way in which it invades the lung tissue.

"Croupous pneumonitis" invades with its exudate the air cells of a lobe or lobes. It is common to "all ages" and comprises about seven-tenths of all the forms reported.

"Catarrhal bronchonitis" invades first the bronchioles, then the vesicles and interstitial tissue of both lungs with its catarrhal or mucopurulent exudate. It is "mostly confined to children," and embraces about three-tenths of all the cases reported.

The great mortality attending this disease at present makes its study one of the most important within the realm of medicine.

Its causes are multiple; next to taking cold, a predisposition to it is the most frequent.

It is a peculiarity of the disease that at the time of a "normal crisis" the temperature is liable to become "subnormal," and this condition may occur and a state of collapse may supervene when positive antipyretic measures have been omitted altogether. This unfortunate circumstance was common in countries where "quina" was used in unreasonable doses, and the "cold bath" was improvidently employed.

It was common everywhere when the "coal tar derivatives" were used in positive doses.

The treatment here outlined is conservative. It is simply a peaceful invasion of the domain of nature, a clasping of the outstretched hands and a mutual declaration of dependence in times of dire distress.

The preliminary purgation is best accomplished by a single dose of 10 or 30 grains of calomel triturated with one grain of sodium salicylate, assisted in four hours with a three-pint sylster of warm salt water. From one to two teaspoonfuls of chloride sodium to each pint of water should be used, according to the amount of intes

tinal stimulation required. Lavage of the colon, with the foregoing solution, should be practiced once daily during the continuance of the case unless specially contraindicated. Then sterilized water alone should be used.

The salt supplies that chemical to the system which an analysis of the urine indicates is lacking, and the water supplies the system with that element without burdening the stomach with it. It will soothe the stomach and intestinal irritation, lower the temperature, and materially modify the progress of the disease.

If the stomach is irritable, give "ice" and apply a "sinapism" to the epigastrium. If chill is present, use heating agents internally and externally, that the blood may be gotten back to the surface immediately. When reaction occurs with augmentation of fever, commence at once with

Ice Water and Fanning

Ice water to the entire head and back of neck and "fan" the thoroughly moistened or "douched" parts vigorously and constantly (avoid the ears), wet the hands and wrists, get the water between the fingers, and then lay outside of the cover to cool. If fever is excessive, wet the feet also.

The room should be large and kept as free from excitement as possible and at about 70 deg., Fahr. It should be ventilated by admitting air from an adjoining room to which pure, fresh air has been daily admitted. At the time of the "crisis" or during the application of the heating agents the temperature of the room should be not less than 80 deg. or 85 deg. (If the outdoor temperature is favorable, 80 deg., throw open the windows.)

The fresh air advocates" declare it to be a specific in this disease,

If this is true, why the alarming death rate? And why are the number of cases increasing, rather than diminishing?

The writer employed "cold air" in the treatment of scarlatina twenty-eight years ago. It "relieved," as it will any form of dyspnoea. The scarlet hue of the eruption soon paled, the dyspnoea diminished and the temperature was promptly lowered. He thought that he had discovered a specific, but soon found that more trouble from sequelae resulted than he had had to contend with in the primary disease. The

patients became subject to various forms of kidney trouble; had waxy kidney, evidenced by the peculiar waxlike color of the skin, and parenchymatous degeneration with uraemic convulsions. A low grade of secondary fever, with gastric and intestinal disturbances, often complicated and retarded convalescence. Again "catarrhal bronchopneumonitis," as a terminal affection, a terminal affection, developed with its train of neurasthenia. All these troubles were found to be due to the patient taking cold from the exposure at the "critical time" of the defervescence of the fever, which occurred about the fourth or fifth day. It was found to be a dangerous experiment to trust all classes of cases (mild, severe and malignant) INDISCRIMINATELY, to the effect that the varaible meteoric condition of the "outdoor air" has upon the rapid and imperfect metabolic processes which are going on within the assailed organism. It was found that only the very malignant cases, those as red as a boiled lobster, with a high temperature, and panting respiration should be treated with "fresh air" in scarlet fever, has kept the experiment from being repeated in "pneumonitis."

The cause of the present increased prevalence and death rate in this disease is largely due to the intemperate and inconsistent practice of sweltering in overheated and crowded day apartments, workshops, theaters, churches, etc., and the violent change from there to rooms with "wide open windows" at night and chilling temperature as sleeping apartments; the exposure attending fashionable attire; the degeneration produced by luxurious living; the scientific proclamations heard at times that colds as well as "pneumonitis" are caused only by germs, and that the indulgence in alcoholic liquors is conducive to health and longevity. The preaching and practicing of such doctrines have a demoralizing effect upon the habits of the people, especially the careless and indigent, causing them to neglect even the ordinary precautions against taking cold, and to become prodigal of those things which contribute towards constructing and maintaining a vigorous organism. (The writer trusts that the reader will allow this etiological digression.)

Several years ago I was called to see a patient dying with "pneumonitis," on a cold, rainy day in April. He was lying with his bare breast exposed to the depressing, aggravating, "cool," damp, fresh air," which was admitted through the open windows. The air was not sufficiently cold to effect a material reduction of his temperature and his face was alternately congested, blood red and mottled. He was begging for more air. I gave him a hypodermic of morphia and atropia, wet his parched brow with ice water,

covered his chest and commenced fanning him. He was at once relieved, and said: "If this had been done sooner I might have recovered. You can put the windows down now; mamma will take cold." She did take cold and has suffered from bronchitis ever since.

The "fanning" has a more decided effect in lowering the temperature than the ice cap. The philosophy of it is that the water is more quickly evaporated and the heat, as fast as it comes to the surface, is rapidly radiated and carried away, while the ice simply substitutes its cold for that of the heat in the circumscribed area with which it is in contact. Its effects, however, are too rapid for the purpose of reducing the "thoracic and abdominal temperature," and the local effect of the ice cap to the praecordium is preferable for that purpose.

The marked relief obtained by this method of abstracting heat is apparent, not only in the tranquillizing effect of it, but the pulse diminishes in frequency and increases in tone and fullness, and continues thus as long as it is practiced, and from a prognostic standpoint the case at once is taken well in hand and the chances for recovery are brightened. More good can be accomplished by the FAN than if all the fresh air of the firmament is allowed to course the patient's bed chamber uncontrolled and undirected.

"Pneumonitis," when uncomplicated," is a short-lived disease, running its course and ending in recovery "by crisis"-in from "one to five days." We, therefore, need not fear the highest temperature. We can promptly control it, but we must stop or restrain the inflammatory process, whether the temperature be low or high, by a conjoined, systematic, constitutional, internal and external antiphlogistic treatment.

The diet is of supreme importance. (Predigested foods of the highest degree of excellence should alone be given until convalescence is established.) One or two tablspoonsful of liquid peptonoids of beef, milk and gluten should be given regularly with cracked ice and sugar, if desired, every two hours, or an equivalent quantity of meat juice." A glass of lemonade made from the perfect fruit is very refreshing and may be given three times daily. The expressed juice from a good ripe orange, sweetened, if desired, may be taken in lieu of the lemonade. Milk should be postively avoided, unless the above forms of nourishment cannot be obtained. If compelled to use it, the quality should be first class, fresh from the clean udder of a healthy cow and free from acidity. Then three or four ounces, with the addition of one or two tablespoonfuls of sterilized lime water, may be given every two hours.

Cracked ice should be consumed very freely, and if sufficient water for the needs of the system is supplied in this form sickness of the stomach will be prevented and nourishment will be consumed in sufficient quantity to meet the necessities of the case at critical times.

Very large doses of medicines should be avoided, particularly those having a depressing effect, as their sudden withdrawal, which is imperative at the time of the "crisis," is apt to be followed by a recrudescence of the fever.

Sodium salicylate in 5 or 10-grain doses, combined with acetanilide, 1 or 2 grains, is a safe and valuable antiseptic, antipyretic, analgesic and calmative agent. Its potency is much enhanced by the combination as represented in the following formula, No. 1, which is designated thus to facilitate reference to it:

M. ft. C. T. No. 1 Signa. One or two every two hours, dissolved in a teaspoolful of sterilized water, with cracked ice and sugar if desired. These doses rarely need to be increased or diminished.

Severe cases should take two of these tablets every two hours. Those of milder type need take one and a half.

In all cases as soon as the "crisis" occurs the dose should be reduced, or the intervals lengthened, and as soon as the "crisis" is known to be firmly established, all medicine, cold drinks and cold applications should be abandoned and hot drinks and broths should be substituted for them and continued throughout convalescence.

The great majority of the cases, if seen early, will come to a "crisis" during the stage of congestion, i. e., within twenty-four hours after prodromal symptoms have manifested themselves, and no exudate will have occurred.

Ice Cap

But if the case is malignant, or fully developed, one in which an exudate is occurring, or has occurred, then it will be necessary to supplement the measures that have been employed by applying a large, well filled ice cap to the praecordium and lower portion of the thorax. Press the air out so that it will hug the parts closely.

Now the temperature must be taken every hour

or half hour from the bowel, provided the patient can not be trusted to hold the thermometer in the mouth. Inspect the parts and anoint the opening with vaseline before each insertion of a tested instrument.

Never omit at this stage of the case to give morphia, gr. 8, and atropia, gr. 1/200, combined with strychnia, gr. 1/40 to 1/30, in addition to the 1/200 grains which formula No. 1 contains. This combination should always be used, especially when circulatory relaxation or weakness is present. It will help prevent retention of urine, which is apt to follow the exhibition of morphia in potent doses, and it is the best universal tonic and stimulant which we possess. This combination should be employed to prevent any liability to shock which the application of the ice might occasion. It should be continued, as occasion may require, for the relief of dyspnoea, pain, cough, restlessness and nausea, between hours for formula No. 1.

As soon as the temperature begins to fall rapidly and decidedly, place a linen cloth under the ice cap, and when the temperature has reached 98 deg. or 96 deg., Fahr., remove the ice.

Watch the temperature and if it attempts to rise above the normal, immediately reapply the ice. If after several hours the temperature refuses to again fall to the normal, remove the ice.

Cantharidal Blister

Rub the surface upon which the ice rested thoroughly with turpentine. Sprinkle the surface of the blister also with it and apply a large, strong cantharidal blister to the praecordium and lower region of the thorax. Cover it and the entire chest with a well made linseed meal poultice, as hot as can be borne. Bind the whole firmly to its position. Let it remain on ten or twelve hours. The poultice will materially help to bring on the "crisis" and establish resolution. After removing the blister, clip the vesicles and reapply a well oiled poultice, changing it every third hour, for twenty-four hours. Then do away with the poultice and apply a very heavy coat of antiseptic oxide zinc ointment once daily for two days. The blister will promptly impel the advent of the "crisis" within the time it takes to draw and the ointment will rapidly heal the blistered surface.

Subnormal Temperatures

If subnormal temperature should occur and it is not attended by bad symptoms, nothing special need be done to restore the temperature to the normal. The author has seen the temperature remain at 90 deg., Fahr., for twelve hours during the "crisis" without any bad symptoms developing. All medicine and cold applications were stopped and warm drinks and foods were sub

stituted for the cold. No heating applications were applied. The patient made an uninterrupted recovery. A tested thermometer registered within twenty-four hours a normal temperature.

For the above condition simply stop all medicines and cold applications and ice internally and git hot beef broth, free from fat, warm beef juice, hot coffee or tea, or hot milk with lime water.

Collapse

But if collapse threatens or occurs, in addition to the above internal heating agents, local hot applications must at once be begun, combined with the very best stimulants which we possess. Several ounces of hot whisky or brandy toddy, served with nutmeg, should be given, or atropia, gr. 1/200, or 1/100 alone, or combined with styrchnia sulphate, gr. 1/30, or camphor, gr. 1/2, or 1 dissolved in sterilized olive oil, or trinitrine, gr. 1/100 to 1/50. The last four should preferably be given hypodermically (the latter method of exhibiting medicines should only be resorted to in times of emergency), or the following diffusible heart stimulant in nervous subjects: Comp. spts. aether, 31, fld. ext. valerian, 31⁄2 may be given. Either of these stimulants which are accessible should be used to meet the exigencies of the case in hand.

The patient should be rubbed with warm soft flannel cloths as often as sweating occurs. This will materially help to revive the fagging

powers.

Moist Cases

If the case is a moist one, i. e., attended by profuse universal sweating, often fanning the sufferer will be sufficient to restrain the temperature, together with the application of hot or cold water to the extremities. Ice to the praecordimu should be omitted in such cases, unless the surface subsequently should become hot and dry and the fever increases. Then the application of the ice to the praecordium, even in this class of cases, should be faithfully tried.

In all moist cases, while the entire surface is bathed in perspiration, if the case occurs at a time of extremely low temperature, reliance should be placed in blisters to establish the crisis.

Asthenic and Adynamic Conditions These types or conditions make up the majority of the fatal cases. With them the temperature is low and fluctuating, often not more than 98 deg., 100 deg., or but a trifle above these figures.

A careful study of this disease reveals its neurotic nature. Add to this individual idiosyncracies and we have a complicated condition to study and treat.

Those who have their attention fixed upon high

temperature alone and neglect the danger signals of the low will never be very successful in the Symptoms and signs are often unreliable inditreatment of this disease.

cators of the intensity of the morbid process going on in the system and lungs in this disease.

A very small patch of croupous pneumonitis, or a limited area of catarrhal bronchopenumonitis will often exhibit urgent symptoms. On the other hand, an extensive portion of lung tissue may be involved and attended by a general lethargy of the symptoms, which effectually masks the gravity of the case, even in those of robust constitution.

Again, the nervous individual will complain, and justly, too, of intense suffering at the very onset because of the severity of the congestion and inflammation raging within, until universal toxaemia, or a gangrenous septicaemia through autoinfection lulls the system into partial insensibility. Then the temperature, respiration, and even the pulse, may beguile us into a sense of false security. In these conditions, or in cases of profound shock, while the devastation within goes on apace and before we are aroused to the true pathological status of the case, it is beyond control.

Why is that a low temperature is harder to manage and subdue than a high one? Space will not admit of a complete answer to this question, but an explanation sufficient for the purpose of making clear the reason why special efforts are instituted for the relief of this particular condition will be found in the fact that the entire organism is nearer death, and when the somatic death process is near at hand, or actually begun, some of the most powerful poisons and chemicals will often fail to hasten death, or produce their usual effects upon animal life. Then blisters will fail to draw, emetics to vomit, ice to chill, heat to restore the temperature, and even the blood to flow from fresh-made wounds.

Sthenic cases may from neglect, bad attention or errors, become asthenic or adynamic, and it is this latter class of cases which are increasing the death rate so alarmingly.

We look upon a patient and wonder why, despite the presence of a low temperature, slight acceleration of breathing, with a weak pulse, but not a palpitating heart, slight nausea and an occasional effort to vomit, a hippocratic countenence, listless, eyes, weariness and tossing of the head and limbs should refuse all medicines, attention and nourishment, and die in a condition of profound asthenia or shock, but such are the conditions and results which confront us at the bedside.

In such an extremity, no matter what the tem