used over again for that particular patient. At present the Health Department finds that large quantities of filthy surgical dressings, many coming, no doubt, from highly infectious cases, are finding their way to the various city dumps via the ash-can route. These dumps furnish a livelihood to a large number of persons who pick over the debris for old iron, bones, paper, rags, etc. Surgical dressings are considered a specially valuable find, since the bandage material is usually in good condition and together with the cotton finds a ready sale for paper stock. In the manufacture of paper, we understand, this stock is not of necessity sterilized, so that the danger of a wide distribution of infectious material is evident. Not only are these materials sold as rags, but it has been found that the bandages have occasionally been sewn together and used for clothing, no doubt without proper washing and disinfection. It would seem unfair to deprive the scavengers of their livelihood and at the same time it is impracticable to supervise their operations. The Health Department, therefore, urges that physicians direct that all surgical dressings be burned so as to obviate this danger. In many apartment houses, especially during the summer time when the furnaces are not in operation, the burning of dressings is not always easy. In such cases, soaking them in solutions of carbolic acid, chlorid of lime or other disinfectants would be a simple matter and quite efficacious.

The Romig Fund

The collection of a fund by the Cleveland Press to defray the expense of an operation upon a blind resident of this city was no doubt actuated by philanthropic motives but it was without sufficient investigation, it was quite unnecessary and inflicted a great injustice upon the profession of Cleveland as well as upon all those who contribute to the support of our numerous hospitals. In several of our free dispensaries are eye clinics with the leading oculists in attendance. In any one of these this patient could have received expert care absolutely free of charge. Even if his condition had required admission to the hospital wards, no charge would have been made if he could not afford to pay.

The average layman perhaps does not understand the extent to which not only the poor but also those who are in better circumstances avail themselves of these free dispensaries. In the

large cities the condition is often so acute as to be known as the "dispensary evil," since it tends to pauperize those able to pay and besides takes the means of support from the practising physician to whom these well-to-do patients would otherwise have to go. While an attempt is made by the dispensaries, assisted by the Associated Charities, to discriminate between these two classes, in any doubtful case the patient is always given the benefit of the doubt lest by mistake a deserving case be refused assistance.

Department of Therapeutics

CONDUCTED BY J. B. McGEE, M. D.

Opium in Typhoid: Thomas McCrae, in the Journal A. M. A. for September 19, considers the use of opium in typhoid fever, and opposes the views laid down in the books as to the indications for this drug. Its general indications in this disease are: first, restlessness and sleeplessness; second, diarrhea; third, hemorrhage; and fourth, abdominal pain. (1) In restlessness and insomnia its use in small doses is sometimes advisable but, if indicated, it often seems better to give small doses of morphin hypodermically. (2) In diarrhea, here, as in diarrhea in general, opium should be the last drug to be used instead of the first, as is too often the case. The cause should be searched for first, for too often this is left to act and opium is given to prevent the result. The diet should be cut down to albumin-water, or, if milk be given, it should be boiled, and sedatives, such as bismuth, may be given. If opium is needed it should be given as the starch and laudanum enema. Given by mouth opium favors distention and conceals the most valuable symptom of perforation, abdominal pain. (3) In hemorrhage the standard treatment is to give opium, especially in the form of the lead and opium pill. He takes exception to this treatment although sanctioned by tradition and authority. The advantage claimed is that peristalsis is lessened but, he asks, what proof is there that this is an advantage? It may lessen the chance of a clot being dislodged, but when we think how rarely a clot is found at autopsy in patients who have died after hemorrhage, the importance of this does not seem great. Against the use of opium there are several points. It increases the chances of distention, in itself a serious matter. In the case of gastric ulcer, distention increases the chances of perforation and the same is probably true of the bowels, and in a considerable number of cases hemorrhage and perforation occur together. Give opium for the hemorrhage and we know the end. It comes painlessly but surely. Any one who has been called in consultation to decide as to the possibility of perforation in a patient who has had large doses of opium, knows how hopeless it is to give any opium. Then, too, the giving of large amounts of opium seems to have an injurious effect on the general condition of the patient. There seems no doubt that the use of the calcium salts, preferably the lactate, is helpful. As a prophylactic, too large doses should not be given, probably 20 grains a

day is enough. In case of hemorrhage the drug should be begun at once, 30 grains a day may be given and for rapid action may be given subcutaneously in one percent solution. To keep the patient quiet, to limit the intake, to apply a light ice-bag to the abdomen, to give the calcium salts, not to give opium, and not to try to do too much, seem the main points in the treatment of this complication, which after all is not usually so dangerous as has been thought. (4) In abdominal pain, under no circumstances should opium be given, for pain is our chief aid in the recognition of perforation. The first thing in the treatment of abdominal pain is to determine the cause; if due to a distended bladder, meteorism or impacted feces, we are not going to help matters, but rather make them worse, by giving opium. If the cause can be found the indications are clear; if it can not be found we must not give a drug which prevents our determining the cause, certainly in the more serious conditions. When the cause is not determined, simple measures, as the application of stupes or small doses of bromid of potassium or codein, may be enough. If not, the use of a small dose of morphin one-eighth grain hypodermically is preferable to the opium and in this dosage it is not apt to mask abdominal symptoms.

Veronal Sodium: In Merck's Archives for October (Med. Klinik), Ziehen draws attention to the therapeutic value of soluble hypnotics of the veronal group, particularly the sodium salt of veronal. Veronal sodium is a white crystalline powder one part of which is readily soluble in five parts of water. Veronal itself requires 145 parts of water. The solution has a very bitter and alkaline taste. Cases were seen in which veronal had little effect, but in which the same dose of veronal sodium given several days later was satisfactory. The opposite condition, however, was also met with and the author is not convinced that the sodium salt shows a superior veronal action. He concludes (1) the action of veronal sodium is the same as that of veronal. Veronal sodium contains about 90% of veronal, hence 0.5 grams (eight grains) of veronal sodium are equivalent to about 0.45 grams (six grains) of veronal. (2) With an empty stomach, veronal sodium will act more rapidly. (3) Veronal sodium is more readily employed per rectum. (4) The taste of veronal sodium is more disagreeable. This is not noticed so much with an aqueous solution, but, if given in powder or tablets, veronal is to be preferred. (5) Owing to greater solubility, permanent solutions of veronal sodium can be readily prepared and other drugs may be added. (6) The by and after effects of both preparations are the same.

Exophthalmic Goiter: G. E. Pfahler, in the New York Medical Journal for October 24, summarizes the results obtained by the X-ray treatment of exophthalmic goiter. There have been recorded at least 51 cases treated by the Roentgen rays, and of this number 42 cases were followed by good results. Good results showed in some instances within 48 hours and almost without exception within a month and in most cases almost complete recovery was obtained in from three to six months. He concludes: (1) Decided improvement may be expected

in about 75% of cases. (2) This improvement consists of an increase in weight and strength and gradual disappearance of the Basedow symptoms. (3) Some improvement should be noticed within a month and after six to a dozen treatments. (4) When this treatment is properly given there appears no danger and he can see no objection to recommending this trial of a month in all cases.

Digitalis:

In the Proceedings of the Royal Society of Medicine for July, A. M. Gossage treats of the tone of the cardiac muscle, and as the dilated, toneless heart has to work too hard and is always in danger of failing, our object in treatment obviously must be to restore some of its tone. It is, of course, possible that this can be done by mechanical means but these are often insufficient and have to be supplemented by drugs. Unfortunately the action of drugs is seldom a simple affair and the results of experiments on animals are not always borne out in the clinical treatment of patients. Digitalis and strophanthus have, in animal experiments, a very similar action, except that digitalis constricts the vessels, while strophanthus does not, and thus digitalis has the greater effect of the two in raising the blood-pressure. Among other vessels, however, it also contracts the coronary arteries, the flow of blood through which is of immense importance to the heart, increase of flow leading to increased size of the heart contraction, and vice versa. Cushing points out that digitalis has two opposing actions on the heart, first as a stimulus and second as a bridle, and that it is difficult to predict which result will follow its exhibition in a particular case. It seems possible that a very large part of the action of digitalis may be explained by regarding it as a powerful stimulus to the heart. very similar to the interrupted electric current in Porter's experiments. It would stimulate the vagus, the muscle directly and the tone. Practically, as Mackenzie has recently pointed out, it is only in cases of dilatation that marked results are obtained, or in other words that digitalis acts therapeutically mainly on the function of tonicity. Improvement often occurs quite suddenly, although the drug may have to be administered for several days before any effect is produced. It is in cases of recent dilatation or recent increase of dilatation, when the muscle is healthy, that the tone of the human heart seems especially susceptible to the action of digitalis. There are of course cases which do not respond to the drug, although there is dilatation of the heart. In these the cardiac muscle is probably severely injured as by the toxin of an acut: fever or by a myocarditis. In other more chronic cases the elasticity of the cardiac wall may be lost.

Official Drugs:

Oliver T. Osborne, in the Journal A. M. A. for October 31, states that with the aid of an honest druggist, by means of our Pharmacopoeia and National Formulary, we hardly need a single proprietary mixture in the medicinal treatment of disease. While advising the use of some of these preparations, he does not wish to be understood as claiming that it is not better to combine one's own prescription better to fit the individual case, but these official preparations preclude the necessity for using proprietaries. As regards

iron preparations, no iron will act any better than an inorganic iron. If there is an idiosyncrasy against it, smaller doses should be used and in fact too large doses of iron are ordinarily given. He defies any "patented" iron preparation to do therapeutically what he can not do with one of the five official preparations he mentions. We do not need a "patented" bitter tonic. We have the compound tincture of gentian, the compound tincture of cinchona, and the tincture of nux vomica, and we need, for bitter tonic purposes, no other. Concerning the long list of antipyretic preparations, cough mixtures, hypnotics and nerve sedatives, he asserts that any physician who thinks he is unable to write the prescription needed for the individual case should set to work to instruct himself in the method of writing for such drugs and arranging such pharmacally and pharmacologically correct combinations as will suit the needs of his patients. In the coal-tar antipyretics, the official antipyrin, acetanilid and acetphenetidinum (phenacetin), fill all the indications needed, and caffein, camphor, soda, salol and any other drug can be combined with them if desired. There are no combinations of cough mixtures or hypnotics that cannot better be combined by ourselves and for much less cost to our patients. None of this, however, should prevent a physician from trying a new drug if he thinks it an honest one, as we should ever be ready to make use of a valuable discovery, but never to further a fraud.

Adrenalin :

In American Medicine for October, Samuel Floersheim summarizes the use of adrenalin in heart affections. It is one of the most powerful heart stimulants known and has slowed a running heart, contracted a dilated and flabby heart, increased the flow of blood, lessened the murmurs when present and has acted most admirably in cases in which a heart stimulant was urgently needed. It has given excellent results when the usual heart stimulants failed, although he does not wish to be understood that in adrenalin we have a superior heart stimulant to strychnin or digitalis, except in selected He quotes Elsner as having used it hypodermically with marked success when strychnin failed. It is especially indicated too in cardiac failure and vasomotor paralysis occurring during general anesthesia. Its hypodermic use is indicated in cases in which diminished blood-pressure exists. In pericarditis with effusion he has aspirated most of the fluid first, and then injected, through the same needle, adrenalin into the pericardial sac with no subsequent untoward effect.

cases.

Serum Disease:

In the Therapeutic Gazette for October (Interstate Medical Journal) Saunders states that very soon after the discovery and general use of a diphtheric serum, the profession became acquainted with a group of phenomena, following the hypodermic injection of normal antitoxic or bactericidal serum, to which the name "serum disease" is now applied. In general, these symptoms consisted of eruptions, and joint pains occurring in a certain proportion of cases. Physicians regarded these symptoms as uncomfortable, though harmless, after effects in susceptible individuals and attributed the rashes to some toxic substance in the horses' blood-serum. This was a mistake. The symptoms observed were only a few of the phenomena which attend a