if the results are disappointing and the case ultimately necessitates surgical measures, the surgeon will find a fairly satisfactory limb upon which to work and which to work and moderately healthy muscles into which to transplant his tendons, instead of, as is so often the case, a more or less hopelessly withered limb, due in part to the initial poliomyelitic invasion, but also being in part a disuse atrophy.

Hydrotherapy also plays an important part in the treatment of this disease. The general circulation and the restoration of the cold and flabby limb are aided by warm baths, and it is the habit of many physicians to order these children to play, for half an hour twice daily, in water kept at a temperature of 98° F. These baths may be followed by a cooler sponging and brisk rubbing.

Proper protection of palsied limbs, by extra flannel clothing, is always advisable. Medicinal Treatment.-Some advantage is to be gained from the internal use or ergot or of potassium iodide, employed in the early stage, while moderate doses of sodium salicylate or of quinine may also be tried. If the child is in much pain or has convulsions, moderate doses of potassium bromide or of Waugh's anodyne, with or without codeine, may be employed as a symptomatic remedy. The general treatment of febrile conditions, a light diet, and laxatives, as stated in the beginning, are not to be neglected. Rest in a prone position in bed is better than constant lying upon the back.

After the acute stage has passed, nourish the child well and keep the paralyzed limb warm. Potassium iodide, may do good. When the paralysis begins to subside spontaneously, it is well to administer strychnine arsenate or the sulphate in a full dosage three times a day, say, 1-67 to 1-50 of a grain for a child three years of age. This remedy is best given at intervals, rather than continuously. It is my rule to use it for a week and then intermit it for three days. The condition of mechanical irritability in unparalyzed muscles, as determined by percussion with a hammer, is a good indication of the degree of the effect produced by the strychnine, and

this agent may be increased up to a definite point of augmentation of this irritation. It is to be remembered, however, that the twitching of the limbs and stiffness of the back usually indicative of strychnine effects are not to be expected in infantile paralysis where the muscles are paralyzed.

Whether general tonics, such as codliver oil, hypophosphites or arsenic, have any effect of a favorable nature, must be left to the judgment of the physician in each individual case. The most important indication during the stage of regression is to preserve the nutrition and function of the paralyzed muscles.

Chicago, Ill.

GEORGE F. BUTLER.

MEDICINAL TREATMENT OF POLIOMYELITIS*

In 1883 Landouzy suggested that zoster should be ranked with the eruptive fevers and made of it a specific and infectious At cermalady denominated zoster fever. tain periods many cases of zoster appear as if epidemic, and some cases do seem possibly, transmitted by contagion. Trousseau, Kalmann, and Besnier reported cases, and more recently Thibierge, Sicard, Widal, and Jean Minet have added to their num

ber. These have tended to establish relations of undeniable contagion between zoster with eruption and the malady without eruption. In a recent number of the Paris Médical Cruchet develops this further. Within a month his clinic at the Bordeaux Hôpital des Enfants saw five cases of zoster in patients whose ages varied between 18 months and 12 years. The quick succession of these cases of a malady that is rare in childhood favored the idea of its epidemic character. In the case of the baby a real contagion seemed to have been established. This child was brought to the hospital for an attack of slight bronchitis and occupied the bed next to a girl of four years who had intercostal zoster. Three days later the disease appeared in the younger child. The only treatment mentioned by Cruchet was the application of a powder of talc and bismuth.

*Reprinted from The Medical Record.

Osler described zoster as an acute specific disease of the nervous system with a localization in the ganglia of the posterior roots. Strümpell says: "It is not impossible that many of the apparently 'idiopathic' neuralgias are to be referred to infectious causes, for instance, in intercostal neuralgias associated with an eruption of zoster." Again: "The attacks of zoster often exhibit a certain epidemic and sometimes even an endemic disturbance, so as to suggest an infectious agency. The almost constant swelling of the neighboring lymph-glands also favors the theory of the existence of a true inflammatory neuritis."

The text-books are not remarkable for the extent or clarity of the data they afford on the treatment of this painful malady; yet it is one for which we possess a remedy whose efficacy is so certain and uniform that we may make it the starting point for further reasoning. I refer to the phosphide of zinc. In 1890 I had a typical case of zoster in the person of a Jewish youth at Bedford Springs. The family were quartered in an old building whose walls constantly dripped water even in the warmest weather. The hotel lay in a valley too much shaded and with too little circulation of air for health. Any infectious germ once present had abundant opportunity to develop and multiply there. The treatment was ineffective until he was given zinc phosphide, in doses of a centigram an hour before each meal. Within two days the attack was under control and recovery was speedy and uninterrupted.

At that time we looked on zoster as the peripheral manifestation of disease affecting the corresponding spinal roots, without a thought of its possible infectious nature. Acting on that theory I sought to extend the use of zinc phosphide to other cutaneous expressions of central nervous diseaseprocesses, and with considerable success.

Some curious instances of the applicability of this therapeutic doctrine occurred. I looked on the remedy as a possible inciter of nerve activity by the use of which the reparative processes were set in active operation and perhaps a requisite food element supplied. But if zoster is an infec

tion the applications of zinc phosphide must be explained otherwise, and the field of its possible utilization is immensely widened.

We begin to call to mind that phosphorus has been lauded as a remedy in certain phases of pneumonia, and possibly there is something worth developing in its therapeutics. For instance, zoster is a malady affecting the posterior spinal roots. Is it possible that any remedy can be so narrowly differentiated that it cures an infectious malady affecting especially the posterior spinal roots, and does not similarly act upon another infectious malady. mainly affecting the anterior spinal

roots?

It seems legitimate to give zinc phosphide a trial in acute anterior poliomyelitis.

It is my firm belief that many infections occur through the alimentary canal, more than have been as yet suspected. Apart from this, fecal toxemia contributes one element to every febrile malady, which is deleterious to the patient and renders his suffering greater, besides lessening his chances of recovery. For in every fever there is a diminution of digestive secretion, usually constipation, and an enormously increased radiation of water from the body; the absorption of fluids from the bowels is increased during a time when by reason of greater heat and lessened disinfection the bacterial operations are stimulated, and toxins are produced in larger quantity and probably of greater virulence. From these considerations the rule is deduced that in every febrile attack the bowels must be completely emptied and rendered as nearly aseptic as may be possible. This having been done, the affected nervous tissues, abnormally sensitive from the effect of the increased temperature, are not further depressed by being fed with a blood contaminated by fecal matter. The observation of very many cases of various febrile diseases has confirmed me in this belief, and I have been led to compute the part of the attack subtracted by the elimination of this one element as about one-third, or 33 percent, of the entire symptomcomplex. If such an attack is thus deprived of one-third of its gravity, the dif

ference in prognosis is far more than 33 percent.

This having been done in a case of poliomyelitis, the way seems open for a trial of zinc phosphide as above suggested. The great difficulty is that it is purely experimental. We do not know exactly what the remedy does, or may do, here or even in health. As usual in investigating drugs we come up against the blank wall of our actual ignorance of their exact nature and the influence they exert over the bodily functions. When we ask why any cure is effected we come to the point where experiments should be made and have not been; and the want of data that could be supplied in this way prevents us from comprehending drug action and extending the use of remedies found valuable in one case to others that may present similar features. Has drug investigation been completed? It has scarcely begun. There is something in the salts formed by direct union of two elements not to be found in the oxygen salts. Calcium sulphide is not identical therapeutically with calcium sulphate. The phosphide is not equaled by the phosphate, or the nitrite by the nitrate. We standardize our nuclein by its content of phosphorus; we judge of neuro-lecithin as a phosphorus pabulum; we have had the hypophosphites urged as remedies for tuberculosis, the glycerophosphates as general vitalizing tonics, the phosphide of copper as an antituberculosis agent, and many other therapeutic suggestions based on the presence of phosphorus in the preparation; and all this on the assumption that phosphorus in some form performs valuable feats in the body. But just what does it do and how? Beyond the rather apocryphal repute of phosphorus in impotence, this element is scarcely established in any malady except rickets and osteomalacia, where its power of increasing the deposit of lime salts in the bones is utilized. While it has been recommended in neuralgias and many diseases of the central nervous system, Cushny questions whether it is of any real benefit in these maladies. Wood found phosphorus "apparently act favorably" in the acute nervous exhaustion of typhoid pneumonia. He pronounces it a

nutrient tonic to the nervous system and as such applicable in chronic nervous exhaustion, threatening cerebral exhaustion, or myelitic paraplegia from excessive venery, but while mentioning other applications he does not give them his personal endorse

ment.

Like arsenic, we find plenty of testimony as to the toxic powers of phosphorus. It increases the autolytic activity of the liver, occasions the transfer of fat from the periphery to the internal organs where it is not wanted, and induces jaundice, necrosis, and connective-tissue hyperplasia. Phosphorus itself is not germicidal, since large colonies of microbes flourish on sticks of solid phosphorus; but neither is pure sulphuric acid caustic, and the phosphides may be more active in this direction. control exerted over herpes zoster by zinc phosphide finds no explanation in any data furnished by the textbooks on therapeutics. That this control is nevertheless real may be proved by any who will put it to the test of actual clinical application. That alone can determine whether this power extends to the disease known as acute anterior poliomyelitis. The experiment is legitimate.

The

Zinc phosphide should be administered in doses not exceeding a centigram, for an adult, and one hour before meals so as to keep it away from the influence of the gastric juice. As a sedative in this group of affections gelseminine far exceeds morphine, especially in that the former tends to favor elimination instead of locking toxins up in the body.

Chicago, Ill.

WILLIAM F. WAUGH.

EXAMINATION QUESTIONS

1. Tell something of the etiology of acute anterior poliomyelitis.

2. What are the indications for treatment during the acute stage? Tell how you would treat a

case.

3. What are the aims of treatment during the second stage? How do electricity, massage and mechanical movements prove useful?

4. Outline a scheme for medicinal treatment in the second stage.

5. Tell something of the value of phosphorus combinations in this disease.

6. How may gelseminine prove useful? formin? intestinal antiseptics? calcium sulphide?

CABOT'S "DIFFERENTIAL DIAGNOSIS"

Differential Diagnosis, Presented Through an Analysis of 383 Cases. By Richard C. Cabot, M. D. Profusely Illustrated. Philadelphia and London: W. B. Saunders Company. 1911. Octavo, 753 pages. Price, cloth, $5.50 net.

While the number of textbooks and monographs on the diagnosis of disease is large, the exceedingly difficult subject of differential diagnosis has been treated rather by the way, and hardly ever in a deliberate and special treatise, so that physicians often are obliged to search their memories for what they remember from clinical lectures or wade laboriously through textbook after textbook in the search for a particular discussion.

It does seem strange that the plan followed by many clinical teachers, of analyzing their cases from the presenting symptom up through the entire clinical picture or symptom-complex, and of discussing each possibility, has never been adopted in a treatise on diagnosis, but whatever may be the reason, Dr. Cabot is a pioneer in this as he is in other matters. In the language of the author, "cases do not often come to us systematically arranged like the account of typhoid in a textbook of practice of medicine. They are generally presented to us from an angle, and with one symptom, often a misleading one, in the foreground." This one symptom the author calls the presenting symptom, and from it he reasons upward, using it together with the other symptoms as leads to the actual seat of disease.

In this mode of reasoning a fair knowledge of the clinical pictures of diseases is of course prerequisite; for, as the author

says very truly, "correct diagnosis depends upon what enters the doctor's head as possible and on what his head does to sift the possibilities after they have entered it, as well as on the direct recognition of signs by physical examination."

The subject-matter of the book is arranged according to leading symptoms, such as pain, headache, lumbar pain, general abdominal pain, fevers, chills, and so on. After brief general discussions of such symptoms as pain, fever, and so on, casehistories are presented, just as they were received, with the results of the examinations. In the discussion, the leading symptoms are considered and the different possible diagnoses detailed. The tentative diagnosis is then shown to be either supported or refuted by the further history.

In the selection of cases none were chosen in which the diagnosis was obvious and none in which it was impossible or dependent chiefly upon good luck. The cases which are described are such as may occur in any physician's practice, and their clear, concise discussion will, there is no doubt, aid many a practician in many a puzzling and difficult contingency.

The book has, however, another, and a very important raison d'être. Its careful study will not only teach us to recognize cases similar to those here described when we meet them, but it will insensibly teach us to adopt a like mode of analytical reasoning and to apply it to all cases that present themselves to us. We consider this by far the greatest merit of the work. For this reason, we can not call the unavoidable limitation in the diseases discussed a misfortune. The book might have been made twice as large and have given double the information, and yet it

would not have fulfilled its purpose any better. For, if we understand the author correctly, his principal aim was not so much to describe certain diseases. For that we have many excellent textbooks on diagnosis. It was rather to teach us to think constructively and to make our correct deductions from the symptoms together with the best means of examination and investigation at hand. This aim certainly has been accomplished, and the book is cordially recommended to every one of our readers.

H. J. ACHARD.

HARE'S "MODERN TREATMENT”

Modern Treatment. The Management of Disease with Medicinal and Nonmedicinal Remedies. By American and English Authorities. Edited by Hobart Amory Hare, M. D., assisted by H. R. M. Landis, M. D. Two Volumes. Philadelphia: Lea and Febiger. Price, per volume, $6.00. Occasionally, among the multitude of medical books published, some work stands out preeminent, the importance or novelty of its subject-matter compelling the interest of a large part of the profession. Unfortunately the average textbook on Practice or Treatment contains but a small amount of really new and useful information, a preponderating proportion being rehashed material-the theories and methods in vogue fifty years ago presented in modern habiliments. To a certain extent this, of course, is unavoidable, for fundamental therapeutic principles and definite physiologic facts must be set forth by each author; still, too many writers turn out pretentious "textbooks" when a brochure or a small "handbook" would easily contain their individual ideas, so that it is necessary to wade through a sort of predigested cold collation in order to enjoy the pièce de résistance, while now and again-more's the pity-one finds nothing but the mere uncomforting "cold collation."

So it is a pleasure unalloyed to note that "Modern Treatment" is distinctly a new and most complete presentation of the subject discussed. Editor Hare points out that, whereas heretofore the means in our

hands for the cure or alleviation of disease consisted chiefly of a limited list of drugs, besides climatic, hydrotherapeutic, and electrotherapeutic methods, we have, today, serums, vaccines, and specific remedial agents of inestimable value and which may be employed by the most remotely located physician.

The hard-working general practician cannot, by any possibility, read a multitude of books, neither can he keep au courant with therapeutic advances, by diligent perusal of medical periodicals; hence a book which places in his hands a complete summary of these matters is essential, indeed.

As we have so often pointed out, it is the man who treats his patients effectively who wins success, and to secure results it is necessary that well-tried and efficient remedial agents or methods be employed. We are passing through a period of change: theories advanced today are accepted or disproved within a few weeks and, not infrequently, things enthusiastically approved for a time are, upon more extended trial, utterly discredited.

The conscientious physician, therefore, will try to steer an even course; he will not be unduly conservative and practise medicine as his preceptor practised; neither will he adopt, offhand, every new method promulgated, and thereby endanger his patients as well as his own reputation. He will think seriously and hesitate before he uses a remedy on hearsay or on the advice of some self-appointed mentor, but when his own good common sense approves the newer procedures advocated by competent men, he will adopt them, possibly with modifications demanded in his particular line of work.

The man who from lack of knowledge (or energy) ridicules every modern therapeutic procedure, because it has not what he is pleased to call a "scientific foundation," is in reality unscientific. He is, moreover, likely to be unsuccessful. The really competent practician of today must be an investigator; he must keep informed, and at least be prepared to test rationally presented remedies and methods. To that which proves good he must hold fast;