six hours. Then ordinary medication is continued, i. e., the indicated remedies are given every two, three or four hours, or one remedy every three hours and another every four, with perhaps, a night-dose of some laxative or a saline laxative in the morning. Many thousand country practicians use the alkaloids daily in this way and obtain results heretofore deemed "impossible". Surely this fact proves beyond question the ease of exhibition.

Moreover, the doctor using the active principles knows that he is administering definitely acting remedial agents. He practises precise therapeutic methods. He does not merely treat named diseases or exhibit compounds of unknown strength and action -some combination of drugs said by someone to be "a specific for" this or that disease. Each granule contains a definitely known quantity of a drug that exerts a positive action, and if the small dose is given at intervals, the desired effect must be obtained, provided the diagnosis and selection of remedies are correct. If the doctor has erred in either direction, the physiologic effect of the drug will be manifested before the remedial action. Thus the practician is warned of his error and can revise his medication. This last sentence applies particularly to the more potent alkaloids, for instance, aconitine, veratrine, atropine, gelseminine. If you have a file of CLINICAL MEDICINE, read Query 5558, in the issue for March, 1910.

We think we have demonstrated, doctor, that your conception of the socalled dosimetrist's method is erroneous. As a matter of fact, they do just what you think ought to be done, namely, give the effective dose every two or three hours. Now and again, it is true, a granule is ordered every fifteen to thirty minutes, but the conditions present in such cases are serious and the rapid medication is maintained only for a short time. No human being objects to watching the clock for an hour or two and giving medicine twice in the hour when some loved one is seriously ill, especially if by such medication remedial results can almost invariably be obtained.

The writer himself has practised in the country, and had as many as twelve or even

twenty patients under treatment the same day, and day after day, and has yet to experience any difficulty whatever in getting the active principles given in the proper manner. Adults who are not very seriously ill can readily "reach for" and swallow a granule on time, and even small and very sick children take the practically tasteless alkaloidal granules without protest.

QUERY 5733.-"Hematuria: Possible Vesical Lesion." H. M. B., Nebraska, forwards a specimen of urine and rather incomplete clinical data and asks for diagnosis and treatment. The patient, married woman, complains of pain in the abdomen and when passing urine, also of frequent micturition, blood being constantly present in the urine. The doctor wishes to know where the blood comes from, whether from kidney or bladder, and, in addition to a complete urinary analysis, wants urine to be examined for the tubercle bacillus.

The report of the pathologist shows absence of tubercle bacilli, alkaline reaction, presence of squamous epithelia, amorphous phosphates, triple phosphates, and a moderate amount of blood. It is impossible, from a simple examination of the urine, to say just where the blood comes from. Casts are absent. We are inclined to think that the lesion is in the bladder. In order to be certain upon this latter point, you might inject 10 to 20 grains of potassium iodide in solution into the bladder. Half an hour or an hour afterward, have the patient expectorate into a starch paste containing a little nitric acid. If there is a break in the bladder mucosa, the iodide will be absorbed and excreted in the saliva in from one-half to two hours. The nitric acid will cause the liberation of the iodine and the starch will assume a violet color. Bear in mind, doctor, that there is no absorption whatever from a normal, intact vesical mucosa; hence, no absorption of the iodide and consequent discoloration of the starch paste.

The patient may suffer from a tuberculous kidney. The negative finding in this case is of very little value. We suggest the inoculation of a guinea-pig. The time required for this test is six weeks. Or you may try the Von Pirquet reaction.

T has been my good fortune to meet

good many failures. There isn't much. difference between the two as regards ability-nor have I found much variation as to opportunity; yet the reasons for the success of the one variety stuck out all over them like seeds on a strawberry.

1. They wanted something.

2. They knew what they wanted. 3. They determined to get it.

4. They believed they could get it. 5. They took thought as to the best way to get it.

6. They went to work to get it, and kept working, and as fast as they were knocked down they got up and went at it again.

And they won out at last.

The last item is especially importantsome men seem to form the habit of being beaten.

It is necessary for the well-being of man that he should be dissatisfied. He must want something he hasn't got, and want it badly enough to be willing to exert himself to the full extent of his powers to get it. And while a man may not be able to lift himself off the ground by pulling at his bootstraps, yet, when by earnest tugging he has lifted himself to a higher level, he will find that he has pulled a section of the

No. 10

world up with him. That's the way humanity makes progress. The contented, unambitious man gravitates toward a level and pulls the world downward with him.

We all want a lot of things: money, ease, power, fame, usefulness, pleasure, experience, knowledge, pie. An early lesson is to decide what we want most, and concentrate upon that our efforts. At first it's pie, until we learn the distinction between the temporary and the permanent. Then it's a girl. Nowadays the modern Jacob rarely has to labor fourteen years for his Rachel. She won't wait for him, but will take up with Esau, or if she really prefers the smooth-skinned type, will coax old Laban around in about fourteen days. But Rachel still likes to feel that Jacob considers her worth fourteen-years' sheepherding, and she is.

Whatever it may be a man chooses as his one want, he must treat it as the grower of big flowers does-pick off all the others and let everything go to feed the chosen one. So much the more reason one should be thoughtful in making his choice.

The battle is half over when one makes the resolve that he will win. That means that he will try, earnestly, thoughtfully, confidently; and people respect a

when they realize that he means business. The fellow who gets a job is the one who goes in and claims it. The others ask for it.

The successful man makes his brains work and to direct his hands. Headless work is poor and ineffective work. Napoleon swept up the Neapolitan lazzaronithe scum of the world-and made of them an army that overturned empires. Mohammed gathered in his hands a wild Asiatic rabble and welded it into a thunderbolt that crushed Greece and Rome, Persia and Egypt, and tore the Orient from its allegiance to the Cross. Brains made of the Kearsarge an ironclad and it won her battle. The same resource was open to the Alabama, but her officers hadn't the brains to avail themselves of it. It is not the best soldiers or the greatest resources that win battles, but the brain that so utilizes the means at hand as to make them win.

After all, it comes down to work. The hardest worker wins out. The man who puts in more and better thought, more time, more labor, takes more pains, wins at the last. Few admit that the cause of their failure was innate. Lack of opportunity, fraud, graft, influence, all these are mere excuses to cover out of sight the real difficulty, the weakness that marred the plans.

Men make their own opportunities; they see them where others fail to look. They foresee difficulties, guard against fraud, and oppose to "pull" that actual worth which no captain of industry dares disregard. The sort who succeed do not let themselves be fooled or overlooked. Were it otherwise, were the world today to be governed solely by graft and pull, it would be time for another deluge.

Each and every one of us may lay this unflattering unction to his soul, that he has gotten in results exactly what he deserves, just what he has earned. People pay us what we are worth. People love us so far as we are lovable. People respect us in so far as we are respectable; in a word, the world forms a fairly correct estimate of us, and values us accordingly. If we are dissatisfied, it is up to make ourselves worth

more,

us to and to

make men know our actual capacities and possibilities.

The clinical therapeutist often gets results by means or methods which are based upon empirical observations without being able to bring forward an exact explanation of how they do good. For the time being we must be content to let his knowledge rest upon his results, and hope that future investigation will explain in a scientific manner the processes in the body which are involved when he resorts to a well-tried and successful plan of treatment.-H. A. Hare.

THE TUBERCULIN-TESTED COW

Through the courtesy of Dr. James A. Egan, secretary of the Illinois State Board of Health, we have received advance information on an article which is to appear in the forthcoming Bulletin of the State Board of Health, in which Dr. Egan gives the reasons why he opposes the indiscriminate application of the tuberculin test to

COWS.

Dr. Egan's principal objection to this test is that, if indiscriminately applied and insufficiently interpreted, it does not afford any assurance that the cow so tested is free from tuberculosis, and that tubercle bacilli are not freely discharged into the milk.

It is well known that in the advanced stages of tuberculosis, the power of the organism to react to tuberculin may be abolished, and that in generalized tuberculosis the same may be true. In fact, in general miliary tuberculosis, the tuberculin test is frequently negative. We agree with Dr. Egan that a tuberculin test of itself, without attention paid to clinical findings and to environment, is insufficient and does not protect us from the possibility of receiving milk from tuberculous cows. all practical purposes, physical examination, which should be particularly careful as regards the condition of the udders, is of greater importance, because as a rule milk is only infected if the udders are involved by tuberculous disease. The healthy milkglands do not secrete tubercle bacilli, even in a tuberculous female organism. This is true in man as well as in animals.

If, therefore, the tuberculin test is to be made as a matter of routine, and the examination of the cows and attention to the strictest cleanliness in the environ

ment of the milch cows is to be neglected, we agree with Dr. Egan that the tuberculin test is futile. It is never to be taken as a deciding factor in itself, and can only form a supporting indication and aid for the diagnosis, which, after all, must be made from the results of a careful physical examination, together with the history of the case. This again is true both for man and for animals.

On the other hand, if a positive tuberculin test is to be made a cause for obligatory destruction of the animal, the method may work unjustified hardship on the owner, because the subcutaneous tuberculin test may be positive when the disease is only slight, when it is healing or healed, and when there is no danger of milk contamination.

While we admit that a tuberculous cow should never be used as a milk cow, it may safely be sold to the butcher, provided the tuberculous process is limited and not extensive. Such meat is, by no means, dangerous, as has been shown conclusively in the case of the German "Freibaenke." This is, however, not the point at issue here and need not be discussed. Suffice it to repeat that the tuberculin test, unaided by other methods, by attention to clinical findings, to cleanliness, and the insistence upon proper environments is futile as a protection against contaminated milk.

Every man to his taste-but I'd rather have an assassin for a friend than a gossip.-Silent Partner.

THE TEACHING OF PREVENTIVE MEDICINE

Until recently, not one of the one hundred and fifty odd medical schools in the United States has given instruction in preventive medicine. Heretofore our sanitary officers have been compelled to learn their work as best they could in the school of experience. It is significant of the increasing interest in public health that three American universities have, within the last few months, initiated special courses for those desiring work of this kind, all these courses leading to the degree of Doctor of Public Health.

Harvard was the first to offer a course of this kind, under the direction of Dr. William J. Rosenau, formerly of the Public Health and Marine Hospital Service. Similar instruction was soon after provided by the University of Michigan, and now we learn that at a meeting of the Board of Directors of the University of Cincinnati, on July 13, a plan for training medical students in sanitation and preventive medicine was presented and adopted.

The last-mentioned institution is really the first to provide instruction in sanitation by what we may call "the labaratory method." The Cincinnati College of Medicine is a city institution, and it is, therefore, quite appropriate that it should cooperate with the Cincinnati Board of Health, which is also a city institution. The new arrangement provides for cooperation between these two. The Department of Health will provide the "clinical" material, while the school itself will furnish any necessary didactic instruction. In this way, the students can be thoroughly grounded in and become practically acquainted with the problems of meat, milk, dairy, and other forms of food inspection; with school inspection; with the methods of controlling infectious diseases; and with proper methods of keeping health records.

Every student in this institution will be given an opportunity for active practical service with the Board of Health, the classes being distributed among its various departments, to do chemical and bacteriologic work (the examination of milk and water, and testing for typhoid fever, tuberculosis, diphtheria, etc.,); to do sanitary inspection and fumigation; to trace the sources of infections; to make food, dairy, bakery, barber shop, and school inspections; to practise preventive inoculation and vaccination; to study the methods of disposal of sewage and of the dead; and to serve in the city dispensaries. Students will also participate in the work of The Antituberculosis League. They will take part not only in the laboratory and field work of the Board of Health, but also in its office work, studying methods of making reports, of compiling statistics and keeping records.

This is a real forward step, one which should be imitated by other medical schools.

If you are on the Gloomy Line,

Get a transfer.

If you're inclined to fret and pine,

Get a transfer.

Get off the track of Doubt and Gloom,

Get on the Sunshine Train-there's roomGet a transfer.

THE CHANGE TO ALKALOIDS

Strong is the force of habit. Men insensibly get into grooves, and it requires a distinct effort to break out and direct thought and action into new channels. Many men are persuaded of the advantages derivable from the pure alkaloids, but are uncertain as to how to begin with them. It looks difficult, and only when one has formed the habit does he realize how easy and natural it is.

The first difficulty is the prescription habit. One has been accustomed to the use of a set formula, never varying the ingredients or proportions, so that this new idea of prescribing singles for conditions. seems very scientific but difficult. In reality, it drops a burden from one's back, and places the doctor where he should be, at the bedside, estimating the disorder in his patient's machinery. Instead of waiting until the name of the malady can be written into the history-sheet, it attacks the most prominent factors as seen in the patient before our eyes. Before long the advantages thus gained will be realized.

Don't try too much at first. Select a dozen of the most generally applicable remedies, and study their powers carefully. Aconitine, veratrine, digitalin, strychnine arsenate, and their combinations, in fevers; atropine or hyoscyamine and glonoin; calomel and saline laxative; cicutine or gelseminine; the sulphocarbolates; pilocarpine, emetine, calcium sulphide. When these have been mastered one can do nine-tenths of his work with them. The other tenth will require many other remedies, more than we possess, but these can be added as the need for each arises. Get the method of direct medication firmly fixed into a habit, and the rest develops itself.

A routine is essential, because there are certain primary or fundamental facts applying to every human being who is ailing. We begin with the principle that fecal toxemia is a very common occurrence, and always bad. So we give calomel or podophyllotoxin, followed by a laxative saline, and get rid of this disease-factor to begin with. Meanwhile we investigate the eliminants, especially the kidneys, to be sure the channels are open for carrying waste out of the system. This will govern our therapeutics, for we shall hesitate to add to the toxin total in the body if it is already overloaded with poisons that can not be discharged.

Infective invaders are to be dealt with if present, and we turn to calcium sulphide to rout them, and to nuclein to reinforce the garrison.

The leading symptoms come next, and we supply remedies for fever, pain, vasomotor relaxation or tension, spasm, paresis, or whatever is most prominent. Only in exceptional instances does the nature of the disease furnish a specific indication, as mercury for syphilis, quinine for malaria. pilocarpine for sthenic erysipelas, sulphide for gonorrhea, or antitoxin for a diphtheria.

But there is growing up a line of specifics for conditions that may become of supreme importance, such as calcium sulphide for germs, berberine for connective-tissue relaxation, gelseminine for spinal irritability, atropine for hemorrhage, glonoin-hyoscy amine-strychnine for shock, collapse and spasmodic pain, aconitine for vasomotor spasm, digitalin for vasomotor paresis. strychnine to restore or enhance cerebral control and accentuate the vital processes, emetine to restore the normal digestive secretions, etc.

I have not mentioned two very common complaints on the part of patients, anorexia and insomnia. Purposely, for hunger and sleep are so absolutely inevitable to the healthy human being that their absence surely indicates the presence of an obstacle, and this must be found and removed. The direct treatment of either, without aiming at the etiologic factor, is a crime.

Pretty nearly the same may be said of the heedless prescription of tonics. Why