TH

HE blood, especially as regards its cells, constantly undergoes changes in its constitution. The red cells, particularly, undergo a phase of altruistic develop ment whereby, like the embryonic tissues, they surrender their reproductive powers for the benefit of the nutrition of the organism. Arrest of development at a certain point, therefore, means a degeneracy whereby the old blood-cells gain, like a cancer, at the expense of the organism as a whole. It is this condition that essentially constitutes what is called pernicious anemia. The red blood-cell in this disease has the embryonic potentialities of the cell in cancer. The factors underlying this arrested cell development of the blood imply more elements than the simple incapacity to take up iron and act as a carrier of oxygen.

The autotoxemia and constipation which constitute the great danger of pernicious anemia are clearly the products of more than the suboxidation due to the imperfect oxygen-carrying powers of the red bloodcells. There is, as any analysis of these cases will show, a toxemic element precedent to the pernicious anemia, which either arrests completely the proper development of the blood-cell, or which disappears, having produced merely temporary effects that disappear with it, as in the many cases of cures of alleged pernicious anemia resultant upon ameboid dysentery, malaria, syphilis, scurvy, diabetes and nephritis, and as exceptionally reported after yellow-fever, acute hepatic atrophy, cholera, and so forth. Here the primitive toxemia is the serious factor, not the resultant arrest of blood-cell development.

The blood-cells contain albuminous matter, as well as hemoglobin and fat. The supply of these, either directly or indirectly, through healthy nutrition, is absolutely necessary. The proper distribution of these substances, in relation to other elements, is likewise needed. The conditions leading to the removal of spanemia are best produced by the employment of alteratives, which improve the nutrition of the body without exerting any very perceptible action on its individual organs. Healthy nutrition depends upon a proper supply of oxygen and nutriment to each tissue and organ in the body, on the proper amount and kind of tissue-change in the various cells, and on the complete removal of waste. The proper supply of oxygen and of nutriment to the body generally will depend upon the state of the assimilatory and digestive organs. This necessary supply of oxygen to the tissues, as well as removal of waste from them, will depend upon the circulation, and the removal of waste from the body generally will depend upon the condition of the lungs, bowels, skin, and kidneys.

Arsenic has a very decided action upon tissue change and it markedly affects the glandular, nervous, respiratory, and cutaneous system. There is no better reconstructive tonic than the arsenates of iron, quinine, and strychnine-a combination that is invaluable in numerous conditions of debility, convalescence, anemia, chlorosis, and faulty metabolism.

Another excellent tonic and alterative is copper. Copper is considered to be a violent poison, yet, except so far as its toxic effects as a foreign body in the eye are concerned, this repute is decidedly undeserved.

Kiernan has called attention to the fact that, among alchemic physicians, copper enjoyed a great reputation for what were later called "nervine-alterative” qualities, and it was used in epilepsy, chorea, and insanity, as Burton's "Anatomy of Melancholy" gives evidence. Its supposititious virtues led Paracelsus to make it the basis of one of his metallic tinctures. From him Rademacher took the therapeutic indications, and his tincture of the acetate of copper is employed by the eclectics today. That the Paracelsian use of copper was never completely abandoned by regular physicians is apparent from the perusal of the two first American Dispensatories, that of John Redman Coxe (1810) and the one of James Thacher (1812). In both of these works copper is recommended as an alterative tonic useful in epilepsy, chorea, and other spasmodic conditions, especially those connected with debility. Later therapeutists sustain this old belief.

According to Philips, J. V. Shoemaker, Biddle, Hare, Lauder Brunton, Potter, Culbreth, Foster, and others, the drug, in small doses, stimulates both the heart and the capillary circulation, and is a general nerve tonic. In the eighth and ninth decades of the nineteenth century copper assumed a new phase in periodic medical literature. Luton and Ligeois showed that copper was of value in chlorosis, anemia, cachectic states, and as a nervine alterative.

Some twelve or fifteen years ago, A. F. A. Price found that, while slow in action on the secondary symptoms of syphilis, copper prevented the development of mucous patches and throat symptoms. The first evidence of copper saturation of the system is stated to be a voracious appetite, followed by giddiness, vertigo, prostration, and other symptoms characteristic of occupational copper poisoning. As with other alteratives, Price had the best results from small doses frequently repeated. In cachectic states, 1-1000 grain of copper sulphate once daily had proved, in his hands, of marked value. Later, he confirmed and extended these results, showing the value of establishing copper tolerance in the pre-parasyphilitic stage.

As to the preparation to be employed, Redman Coxe, Thacher, as also Price, while finding copper sulphate of value, all agree that it has at times unexpected dangerous untoward effects when the point of saturation is reached. These untoward effects, through the influence of the drug on the vascular system, often take the direction of cardiac neuralgias and pseudo anginas.

The double salts of copper in small doses exert a cardiac action similar to that of digitalin, strophanthin, helleborin, etc. Hare prefers copper arsenite. I myself have found that under its use digestion and nutrition improve. It is superior to Fowler's solution in chorea and similar neuroses. Luton and Liegeois prefer a pill containing 1-6 grain of neutral copper acetate and 5-8 grain of crystalline sodium phosphate. For hypodermic use they employ a freshly made solution of copper phosphate, 1 part dissolved in 2 1-2 parts each of water and glycerin. The tincture of copper of the eclectics, which is the old Paracelsian tincture robbed of its crudities, has been employed in chlorosis, syphilis, chorea, epilepsy, neuralgia, and nervous adynamic states, in doses of 3 to 6 minims, frequently repeated, until the evidences of saturation already described appear.

The therapeutic indications for copper, as assumed by Rademacher, are a grayish complexion, sunken features, small, soft, wiry pulse, light-colored, very acid urine, and early nerve symptoms, hallucinations, convulsions, delirium, etc. All of these symptoms are indications of what the older clinicians called nervous adynamia, a precursory suboxidation toxemic stage of neurasthenia.

It is doubtful whether there could be compounded any better tonic-alterative intestinal antiseptic than the sulphocarbolate of copper. The copper, in itself, is a powerful antiseptic, and it acts as a stimulant of the functions of the gastrointestinal glands. In cases of autotoxemia, intestinal or otherwise, the alimentary canal should be cleared by calomel, podophyllin and laxative salines, to be followed.

In toxemic conditions, like secondary malarious manifestations, with the resultant pallor, copper and arsenic are of decided value. Cases in which the periodic tendency has disappeared improve decidedly under copper and arsenic, when quinine and iron alone are useless. The influence of arsenic is very marked on chronic rheumatism and socalled rheumatic gout, neuralgias of various sorts, in tic and hemicrania, as well as in angina pectoris, chorea, epilepsy, and asthma. In certain of the gouty forms of bronchitis, at the onset of phthisis, in imperfectly cleared-up pneumonic lung consolidation, arsenic acts, sometimes, with remarkable efficiency.

In the effects of arsenic and copper just detailed are to be seen the ideal action of the alterative, an action opposed in certain particulars to that of the restorative, to which category iron belongs.

Restoratives not causing tissue change must be placed in a condition for assimilation before the system can receive and apply them. If this does not occur, they act simply as poisons by overaccumulation, whence the many objectionable untoward effects which occur from iron in cases of spanemia, where this restorative agent is not assimilated. In chlorosis, where iron notoriously fails in many instances, copper and arsenic very frequently produce marked and decided improvement, not only as regards the red blood-cell, but also in general nervous vitality.

The fact that arsenic acts as an excellent respiratory stimulant and tonic in mountain climbing, makes it peculiarly suitable in cases like chlorosis, where general airhunger is marked, as in nephritic and diabetic cases. Indeed, in most spanemic states tissue air-hunger is a very unpleasant

feature, sometimes underlying the condition of local exhaustion, and of local pain which provokes local exhaustion.

The fact that the organic irons succeed better than the inorganic is an indication that assimilation is necessary to the influence of a restorative, while an alterative of necessity provokes its own assimilation. Arsenic and copper have been found in small quantities in the thyroid gland, a fact that would indicate their natural presence as an alterative in the system.

The influence of both drugs on the liver, whose double functions are so necessary to the tissue changes of the system, shows that both drugs play a part in assisting assimilation and at the same time in destroying waste products. It must be remembered, as Minot, the embryologist, has shown, that the liver has two functions, one of which is a blood-making, and the other a poison-destroying one. The stimulation of both these functions is necessary to an alterative under the principles laid down.

It is obvious, therefore, that the liver should be functionating properly, the intestinal canal, kept free of toxic material, and free elimination maintained through the various channels, in order to obtain the best results from any tonic treatment.

Prudes form a branch of the great human family, of whom this same family seldom has occasion to feel either particularly proud or greatly ashamed. They do no good that they are responsible for. They live; lead moral lives; are approved of as examples of good children; finally, are respected by other prudes and the owners of other prudes.

Should you become interested in one of the boys of this species, you will discover that he has been held aloof from other boys; was sent to a private school, a fond mother leading him there and calling for him; was ushered into business life by his mother, who saw to it that he was given a desk job and insisted that he must always live at the parental home.

And so he has always remained a real nice boy, who talks of "lovely times" and "horrid times." But he is a mellow, pink-fingered, immaculate, who never "is,"

but "is being"; who never "has," but "has been"; who is an absolutely passive existence. He hasn't a bad habit, because he doesn't know what a bad habit is.

But at times, when his mother carelessly drops the leading string, he is made to look more like a real boy: his eyes are punched, his nose is tweaked, his ears are pulled, he is persuaded to roll in the dirt in order to take the "spanginess" out of his clothes; all of which makes him realize how dearly he loves his mother and causes him to remind her that she has dropped the precious string. He is unable to resist the attack of his tormentors, for he has been taught not to resist. Tears have been schooled to do the work of laughter. His muscles are flabby and his wind is short. He is a girl-boy, a mother's boy. He is a model boy without a bad habit, because his mother has made him an automatic, walking, talking being. He deserves no credit. He gets none.

His opposite is quite as unsatisfactory to the world, and is the result of an equally disastrous thoughtlessness in those who are supposed to be his care-takers.

He is the boy who is allowed the loose rein of freedom, who is allowed to shift for himself; is ignorant of the meaning of the word restraint; knows no guiding hand; hears no loving word; seeks no advice; gets none. He knows the right, but he prefers the wrong. His liberty brings the animal to the surface and he acts the brute in preference to the man. In poverty, he is the ragamuffin, becoming the tough, the sot. In better circumstances, he is the bad boy, becoming the sport.

And the peculiarities of both of these may generally be traced to the wrong use of the right verb. "You shall not" has been used where "you should not" would have made thinking, reasoning boys of them. They have been commanded, not advised. In the one case the one commanded is robbed of all power to question; in the other, he cares not jot nor tittle.

Between these two grow the boys who make the men who make the world. They are the ones who have been taught the

difference between right and wrong; who have had a gentle and loving but firm hand of restraint laid upon them, to guide them harshly but well; who had the right lesson of self dependence, with copious notes on standing up for their own rights.

Grit, with a little vinegar and some ginger, goes a long way toward helping to make a boy presentable in this world of ours. If he has them, don't attempt to take them from him. If he lacks them, do your part to put them into him. Teach him to realize before he is out of his petticoats that whining is unprofitable. Toady to his bump of affection, but teach him that the puppy stage should be outgrown. Impress upon him that, when he gets a few more years and inches, he will be a man to do a man's work; that pluck, perseverance, and push are trouble-shakers; that sound wind, good courage, and a rugged constitution are boon-companions to a healthy brain. Point out to him the right way, and teach him that a part of the task of going that way must fall upon himself. Teach him that to respect himself is to be respected.

If he has a desire to smoke, advise him. not to. If he is determined to smoke, make the best of it. Open the whole house to him, his pipes, cigars and all. The house is his as much as it is yours, and it is a better place for him than behind the barn. If he wishes to play cards, teach him that card playing is not necessarily gambling, and that when he is playing whist and euchre, he is doing nothing wrong. Should he desire to dance, avoid the common canard of the many anxious ones. Teach him, instead, that on the dance-hall floor there are girls of absolute respectability. Should drinking have an inclination to woo and wed him, settle yourself right down to have a vigorous campaign on any lines you choose. Break him!

Bear in mind that the lessons remembered the longest by him are those taught him by you. Be frank to him, would you have him frank; be honest, would you have him honest; be firm, would you have him firm. Be master, not man.

DIEULAFOY'S "TEXT-BOOK OF

MEDICINE"

A Textbook of Medicine. By G. Dieulafoy, Professor of Clinical Medicine at the Faculté de Médecine de Paris. Authorized English translation from the fifteenth edition, by V. E. Collins, M. D., and J. A. Liebmann, Ph. D. New York: D. Appleton & Co. 1911. Price $12.00.

Dieulafoy's Textbook is a work of two volumes and has been written with a special consideration of the needs of the general practitioner.

Volume I is devoted to diseases of the respiratory system, the circulatory system, and the digestive system. In Part I the author has given a complete picture of the tuberculous process as it affects the various organs, embracing the anatomic, clinical, diagnostic, prognostic, therapeutic, and prophylactic considerations. The perfectly systematic and interesting way with which he writes, not only of tuberculosis, but of other diseases as well, makes the chapters nothing less than a pleasure to peruse. Tuberculin therapy and other up-to-date measures for combating this disease are concisely presented. Part III of the first volume is devoted to diseases of the digestive system-511 pages in all-and every page is treated in a most satisfactory manner. The part devoted to diseases of the intestine shows painstaking preparation, the discussion of appendicitis being most exhaustive, embracing 42 pages. Differing from the writings of the average internist, Dieulafoy is most pronounced in his opinion of the value of surgical over medical treatment of appendicitis, as, when he truly says, and with emphasis:

"There is no medical treatment for appendicitis. Medical treatment simply causes

loss of valuable time. It is obvious that the patient can be relieved by injections of morphia, application of ice-bags to the affected region, and other soothing measures; but do not let us be mistaken as to the efficacy of these means. Too often they lead us to believe in cure, when they only mask the symptoms. In view of this fictitious improvement, we speak of typhlitis or appendicular colic, and prophesy recovery; but the patient dies for want of proper surgical intervention. Since this focus (appendicular) is the cause of the disease and of death, would not early surgical intervention be better than ice, purgatives or opium?”

Fifteen pages are devoted to diseases of the pancreas. The author evidently has carefully reviewed the recent and abundant literature, by virtue of which, together with his clinical experience, he is enabled. to clear up many obscure points in diseases of this organ. The pathology of the pancreas has been much simplified, but it is to be regretted that the symptomatology is still quite obscure and the treatment correspondingly unsatisfactory. The portions treating on hemorrhage of the pancreas, on pancreatic colic, relation between pancreatitis and gallstones (pancreaticobiliary syndrome), cytosteatonecrosis, and pancreaticoperitoneal hemorrhage have received a most thorough consideration. The whole subject, indeed, represents the most careful work on the part of the author, making it possible for the interested reader to acquire a complete knowledge of the diseases of the pancreas.

The second volume is equally interesting and exhaustive. It is devoted to diseases of the urinary system, the nervous system, general and infectious diseases, diseases of the spleen, pathology of the blood, rheu