sonally, I wish to emphasize the importance of looking for rheumatic poison, and, if found, treating that.

After trying to correct removable causes comes treatment of the chorea per se.

There are practically two things to be done.

First-Stop waste of nervous energy. It is useless to attempt to fill a barrel with the hose when one has forgotten to put the bung in the bunghole. We cannot get forward in building up the nutrition of the neuron bodies if a constant expenditure be going on-we should try to lessen the jactition of chorea not only because it is disagreeable to look at, but because it means an incessant waste of nerve energy. But we should try, equally, to lessen emotional and mental expenditure. The patient's days should be spent as far as possible in quiet ways. A nagging mother, plaguing fellow children, an irritable nurse, can undo a doctor's best efforts.

So wretched is the atmosphere of some homes that I let a choreic child go to school to enjoy the really more calm atmosphere of school order, although, in general, it is a mistake for a choreic child to attempt the intellectual labor of the school. Calm by day, and sleep, these are the essentials in the stopping of waste. Too much care cannot be given to this matter of sleep.

I make it a routine order that choreics shall go to bed-be in bed, prayers all said and bedclothes tucked in, when the clock strikes eight at the latest-not begin to go to bed, but be in bed.

Another routine rule is to undress the patient, put it in bed in a darkened room for a full hour after the noon meal.

There is generally a fight about this, but unless the mother is a weak sister—a milk and water woman-it can be done. Not a few cases fail to make progress until they are kept in bed all day, in a quiet environment. This sometimes means to bring in a good nurse and keep out emotional mother and relatives.

As for drugs-Sleep at all hazards, without drugs if possible-with drugs if need be. Chloral is the best, although trional or veronal do very well. Chloral is the surest of all soporifics and children usually bear it well. In the ordinary cases of moderate chorea one soon learns to secure a pretty good long night's sleep.

There are, however, ocassionally cases of very grave chorea in which the movements are excessive and violent, the bodily and mental exhaustion profound, and unless something can be done to check it the end is death. In these grave cases the securing not only of some sleep but much sleep is all important.

I recall a little girl of about 10 years, whose condition was bordering on delirum-countenance dusky-feeding almost an impossibility, and I told the parents that the only hope for the child was to put it to sleep and keep it asleep practically all of the time,-that there was a strong probability that the patient might die in any event, but that without sleep, death was certain. I confess that it requires a good deal of courage to give enough chloral to such a child to put it to sleep and held it to sleep night and day, but the thing was done. The child was

roused at frequent intervals to take concentrated liquid nourishment, and spent most of the time night and day for three weeks in sleep. Before the three weeks was up it was evident that the child, instead of growing worse, was regaining some strength, and when the narcotics were gradually withdrawn the child came out and made an excellent recovery. The steady feeding was, of course, essential.

I have seen a number of such cases, and believe very firmly that no other plan would have saved the child.

This brings me to the second principal problem of treatment.that of increasing the nutrition of the neuron bodies. It is largely a question of food supply. These patients, as a rule, have little appetite, and it is no easy matter to secure the ingestion of an abundance of nourishing food. Therefore, forced feeding is important. Now, as all the vital functions are at an ebb, so too, the digestion. It is not enough to give these children three large meals. Even if they eat a large meal, the weakened stomach is liable not to digest it. Wellcooked, nutritious food in small quantities at frequent intervals will accomplish more than attempting to give three large meals.

In considering the question of food in chorea, the part that fats play in cerebral nutrition ought not to be overlooked. Cream, butter, fats of meat, and, if need be, cod liver cil, play a very valuable part. I believe that every neurologist learns to depend upon cod liver oil as much as, if not more than, a specialist in diseases of the lungs.

The problem, however, is not solved when the patient has taken and digested an abundance of food. There is still the problem of stimulating the protoplasm of the cells to take up the food supplies brought to them. Here is where our friend, arsenic, comes in. Arsenic and phosphorus. and probably strychnia, act by stimulating the metabolism of the cell bodies. There is no doubt that some cases respond very quickly to the progressive increasing doses of arsenic, and yet, as a routine treatment. I think it is a mistake. There is such a thing as over-stimulating by arsenic. In so many cases the same poison which damages the neuron bodies impairs also the quality of the blood, so that a certain grade of anæmia co-exists in a large number of cases of chorca. Practically, I have found that iron, arsenic and strychnia in moderate doses give better results than heroic doses of arsenic alone. Conservation of bodily warmth deserves attention; it takes a certain amount of bodily energy to keep up body heat and many choreics need to save expenditure in this way.

The use of raw eggs is also of benefit partly, no doubt, as one form of fat-containing food, but the lecithin of the yolk does, I believe, act in a manner similar to arsenic as a stimulant to cell metabolism. 1331 Majestic Building.

THE DOSE PROBLEM.

By WILLIAM L. WAUGH, A. M.. M. D.,

Emeritus Professor of Practice, Illinois Medical College, Chicago.

The latest revision of the U. S. Pharmacopoeia for the first time in

the history of that compilation has appended to each article the dose. The paragraph in which this addition is announced begins as follows: "After each pharmacopoeial article (drug, chemical, or preparation), which is used or likely to be used internally or hypodermically, the committee is instructed to state the average approximate (but neither a minimum nor a maximum) dose for adults, and where deemed advisable, also for children. The metric system to be used, and the approximate equivalent ordinary weights or measures inserted in parenthesis." Here follows this extraordinary sentence: "It is to be distinctly understood that neither this Convention nor the Committee of Revision created by it intends to have these doses regarded as obligatory on the physician cr as forbidding him to exceed them whenever in his judgment this seems advisable. The committee is directed to make a distinct declaration to this effect in some prominent place in the new Pharmacopoeia."

Evidently this emphatic language was intended to obviate some danger, that appeared to loom so large that it was necessary to guard against it in terms too precise to be misunderstood. What was the danger?

The danger that the doctor might take the dosage given as literally and generally applicable, and that he would thereafter administer the remedies according to it, without taking into account the varying conditions-just butting along in a leaden-headed way until the patient recovered or died; and if the latter were caused by overdosage hold the Pharmacopoeia responsible. Is this the way doctors dose their patients? We very much fear some of them do.

Let us enumerate some of the elements that make a level dose impossible.

Age:-The usual rule is to consider children over 12 years adults and dose them accordingly. Under this age we divide the average adult. dose by the age plus 12, and get the quantity for a child of that age.

Unsatisfactory, and perilous if not corrected by the following: Sex-Men require larger doses than women, especially of narcotics; the women need more cathartics, and special care must be taken in medicating them during pregnancy and menstruation. Habit-drugs are more dangerous to women.

Weight:-This is one of the most important considerations, and furnishes an approximation more nearly correct than either of the preceding. Assuming the average adult weight as 150 lbs., the average dose may be assimilated to the patient's weight, a child of 10 lbs. receiving 1-15 the adult dose, etc.

Strength-While this is an important item there is no fixed rule by which it can be regulated; the doctor must simply make it a consideration in his guess.

The season, mentai and physical state, race, occupation, temperament, weather, climate, conditions of disease, personal peculiarities, "idiosyncrasies," habits, and other questions must be settled. Then we are prepared to take up the problems relating to our drug-what it is likely to do, and how likely; the probable strength as obtained at the pharmacy probably resorted to, the patient's probable reaction to that

particular drug, the chances of his stomach retaining it, the time required to dissolve and absorb the medicinal ingredients, and the probable state of the patient at the time when the effects of the drug are likely to become manifest, etc.

In the face of such complications it is small wonder if the bewildered physician is prone to seek an easy solution, anything on which he may put faith and shift the unbearable burden. Through the maze the experienced practician may thread his way, and make a fair approximation to the dose from which his patient will receive the requisite benefit. But at the very best his dose is only an approximation-a guess-and the best of us are never altogether sure of it. The warning of the Pharmacopoeia is evidently a wise precaution-but nevertheless it destroys most of its possible usefulness, in that it renders the dosage given of little value as a guide on which the physician may rely.

Some hint as to the dose is, however, essential. There must be some guide. Keith refused to affix any doses to his specific tinctures, and prevented their general use thereby. The physician must know whether one drop or a dram is the average. To tell him that eupatorium is curative of acute catarrhs, and hand him a bottle of tincture with no further information, is preposterous. He must know what the drug will do, and how he is to recognize its desirable effects, or he is helpless.

The matter is really simple enough. The Pharmacopoeia should tell us what effects are to be obtained from each drug, how we are to recognize these effects, and the first warnings it gives of the beginnings of toxic action. Then if the average dose be given, and the time required for the remedy to manifest its activity, we are prepared to meet all the complicated considerations making up the dose problem, and to secure not a guess, not an approximation, but absolute certainty and precision as to each remedy we administer, in every case, of every age, sex, and condition, without exception.

Take that same average dose, divide it into a number of fragments each too small to possibly exert a toxic action on the patient we are treating; administer these, preferably in hot solution to obtain quick effects, in rapid succession until enough has been given to cause exactly the degree of effect we desire; then continue in doses to sustain this effect, or if our object has been attained, discontinue the drug altogether. The result is as sure as the multiplication table.

Take hyoscine, for instance: Some patients will go promptly to sleep on doses of gr. 1-250, while others may require five times this quantity. But give each gr. 1-1000, repeated every five minutes-in hot wateruntil sleep supervenes, or dryness of the mouth gives warning to stop. Note the number of doses required, and next time you may administer these at once, if the conditions are sufficiently similar to warrant itin the same case, of course. The next one may require more or less. Every consideration modifying the dose is met by this easy method.

The prerequisites are few and simple: We must know exactly what we want to do, and what will do it. Exactly what our drugs will do, and what evidence of such action we must watch for. What are the indications of the full desirable effects, and the first intimations of over

action or toxic manifestations. If we are not prepared to do this and thus, have we a right to treat the case at all?

Such knowledge as is asked by the above should be placed at our disposal by the Pharmacopoeia; and the physician would wisely limit his use of remedies to those of which such data are available. There are enough of them to enable him to practice successfully in all the varied emergencies of his profession; and when more are needed they should be searched for and added to the list.

THE REPAIR OF CERVICAL LACERATIONS

WITHOUT STITCHES.

By M. R. VAN BAALEN, M. D.,
Detroit.

There are some patients suffering from the effects of cervical lacerations who are unwilling to undergo an "operation" or to take a general anaesthetic for the relief of their condition. A method of repair for such lesions without a general anaesthetic and under the circumstances of an ordinary office treatment, has some advantages. The following method has been successfully used by the author:

First, freshen the edges of the laceration with any suitable instrument as a curette, a dull knife, or the corrugated end of a dressing forcep. This can be so easily and so rapidly done that the patient will experience nothing more than from an ordinary uterine application. After scarifying, insert a stem pessary, modified as follows: A hole is drilled the entire length of the stem of an ordinary stem pessary. Three holes of the velvet eye pattern are drilled in the shaft to increase the drainage from the cervical canal. An aluminum plate slightly larger than the disc of the pessary is now soldered to the disc. The new disc is slightly larger than the external circumference of the cervix. After the stem pessary is inserted, a strip of gauze 1⁄2 inch wide by 12 inches long is bound around the cervix sufficiently tight to bring the edges into opposition. The only method that I have been able to use successfully in the winding is to first bind the gauze around a steel rod which has a slit at one end to receive it. The gauze should, of course, be sterilized and I always dip one end into a saturated solution of beracic acid and permit the crystals to work up into the meshes of the gauze.

After four or five days, the gauze may be removed and the cervix rewound. Ordinarily union will have taken place in from ten to twelve. days.

If the stem pessary is ready, this whole operation may be done in five or six minutes in the office or at the patient's home. The principle underlying the method is simply to hold the parts in apposition until union results. The author has successfully used this method in four cases and believes that it may have a sphere of usefulness.

41 Duffeld Street.