sists of pinhead to lentil-seed-sized, barely elevated, rosy macules which are evenly and discretely scattered over the surface. The eruptive elements are smaller, paler and more discrete than those of measles. At times the eruption may be quite morbilliform in character and at other times the rash may resemble that of scarlet fever, but in any considerable epidemic the exanthem preserves in the main the type which is characteristic of the disease.

Patients, particularly children, are often not sufficiently ill to care to go to bed, indeed, may make no complaint whatsoever, so that the eruption is the first manifestation observed. We usually find a little redness and watering of the eyes, sneezing and slight cough present, but these catarrhal symptoms are much milder than when observed in measles. Indeed, the catarrhal symptoms of a severe rubella are not as pronounced as those of a mild measles. A slight degree of sore throat is usually present, characterized by redness of the tonsils and soft palate. The eruption lasts, as a rule, not more than forty-eight hours and disappears, leaving no evidence behind. There are exceptional cases in which the disease may be more protracted. Generally speaking, however, rubella is the mildest of all the acute eruptive diseases.From the Jour. of N. J. Med. Soc.

THERAPEUTIC VALUE OF ERGOT.

Oliver T. Osborne, M. A., M. D., New
Haven, Conn.-Professor of Materia
Medica, Therapeutics and Clin-
ical Medicine at Yale.

The best preparation of ergot to use is certainly a purified extract, there being no one active principle that represents the activities of ergot. Also, many so-called purified preparations of ergot are useless for ergot activity. Of the pharmacopoeial preparations, the fluid extract is the only one of real value. Several preparations of refined extracts of ergot are stated to have had the principles that irritate and cause gangrene removed, and some of these refined preparations, notably ergone and aseptic ergot, are very active, not irritant, and can be used hypodermatically and for any length of time without causing ergotism.

The principal uses of ergot are as

a

nerve sedative, as a circulatory tonic, as a smooth muscle stimulant, and as a uterine contractor.

The primary physiological action of ergot is to contract the blood vessels, slow the heart, diminish the amount of blood in the central nervous system by contracting the blood vessels of the brain and spinal cord, increase intestinal activity by stimulating the smooth muscle fibers of the intestines, strengthen the diminished power of the bladder by the stimulation of its muscle fibers, and contract a dilated or partially distended uterus best during its paturient activity. If ergot is pushed to its full physiological power, the blood vessels become so contracted as to cause cold extremities, vasomotor tension is greatly raised, the left ventricle of the heart is strained by its endeavor to contract against such resistance and may become dilated and incompetent. Peripheral irritability and sensibility are diminished by the decreased local blood supply, as well as by the greatly decreased blood supply of the central nervous system.

If it is given by the mouth, large doses soon cause irritation of the gastro-intestinal canal, and vomiting and purging will occur, while in physiological doses the amount of urine is increased, probably by the increased vasomotor tension, but in too large doses the amount of urine is often diminished.

How this drug is eliminated is not known. Very likely it breaks up into its component parts and is metabolized, and thus could not be found any more than could the active parts of a mushroom.

Acute disturbance could occur, as above stated, from profound central nervous depression, with dyspnea, very cold extremities, and labored heart action. Chronic poisoning from the administration of ergot I have never seen, nor do I know of any one who has observed it. In other words, I have come to believe that ergotism, with its area of anesthesia, paralyses, and peripheral gangrenes can only occur from eating ergotized grain, and such damaged food products are now rarely or never allowed to reach the consumer.

The indications which ergot meets are: 1. To contract the blood vessels, raise the blood pressure, and stimulate the heart in conditions of shock, collapse, and circulatory depression.

2. To contract the blood vessels of the brain and spinal cord, especially of the meninges, when they are actually inflamed, irritated, or congested.

3. To quiet the nerve pains in inflammation and irritation of nerves, and especially if the origin of such irritation is central.

4. To promote activity of the bowels when there is intestinal muscular debility, paresis, or paralysis, as in tympanites after operations, or where there is obstinate constipation.

5. To contract the uterus in uterine hemorrhage.

6. To ameliorate asthma which is due to nervous irritability or reflexes.

7. To, I believe, modify or diminish excessive secretion of the thyroid, as occurs in some forms of hysteria and in Graves's disease.

8. To quiet the nervous system, and aid in overcoming the morphine, opium, alcohol, or other drug habits, and to increase the potency of any dose of morphine that may be required for nerve pain.

1. The use of ergot to meet the first indication is now well established. When one of the better preparations is used hypodermatically, and best in the deltoid muscle, I believe there is no drug that we possess― except suprarenal, the action of which is so short lived-that can compare in value with ergot. It may be used in any condition of cardiac and circulatory failure, whether it be in typhoid fever, pneumonia, meningitis, operative shock, or shock from injury. Where there is urgency two, three (or even four) hypodermic syringefuls may be injected at one time, the subsequent frequency depending upon the results. The best action both on the nervous system and on the circulation is obtained only when it is used hypodermatically, although it has good action when given by the mouth. We are greatly indebted to Dr. Alfred T. Livingston, of Jamestown, N. Y, for compelling the profession to realize the advantages to be obtained from ergot in cardiac failure. I do not wish to be understood as advocating ergot in cardiac disease where it would be inadvisable to increase the peripheral resistance and thus possibly increase a failing heart muscle. In chronic heart disease it is largely the heart that fails and not an arterial weakness. In acute circulatory failure it is largely the

vessels that are at fault, when ergot would be indicated.

2. The advantages obtained from this drug in cerebrospinal inflammations cannot be too highly lauded. I have already gone on record as advocating the use of ergot hypodermatically in cerebrospinal meningitis, and wish to reiterate that I do not believe any other one drug combined with proper general management of the patient. does as much good as does ergot. I have yet to see a case that was not benefited by it, even if not cured. Also, in any condition of nerve pain I find that less morphine is required if ergot is also given. Besides, in inflammations, I find that in neurasthenic conditions, or in general weakness, where there is sleeplessness, and the stronger, more active hypnotics are best not given, that a dose of ergot at night tends to quiet the brain and produce sleep. It also will often relieve congestive headaches when there is not high blood tension.

3. In neuritis, in referred pains, and in psychic or hysterical pain, ergot is of benefit, and besides the actual advantage is the negative advantage of using a drug which we know can do no harm, which is not true of most of the analgesics, such as the coaltar products, bromides, etc.

4. Nothing is feared more by surgeons after abdominal operations than inactivity of the bowels, with the consequent accumulation of gas, which may cause distention sufficient to interfere with respiration and the action of the heart. Atropine in enormous doses has been used to cause normal intestinal peristalsis, it acting as a stimulant to smooth muscle fiber and also dulling the endings of the peripheral nerves in the intestines, which may have been injured sufficiently to cause inhibitory pain. Eserine, almost the obverse of atropine, has been used on account of its marked stimulant ability to smooth muscle fibers of the intestines. Both of these drugs, as well as various cathartics and methods of using them, have been more or less successful. Probably, however, nothing is more advantageous in this decidedly difficult condition to combat than is ergot, given either by the stomach or better hypodermatically in large doses. In persistent ordinary constipation I have often had splendid results from the addition of ergot to whatever laxative treatment was instituted.

5. The fifth indication to act upon the

uterus is too commonly resorted to to require any discussion. Whether the several other drugs used for this purpose, such as viburnum, hydrastinine, cotarnine hydrochloride (stypticin), or quinine, are ever as valuable, or what are the special indications for each is not in the province of this r per to discuss. I might parenthetically say that the administration of mammary gland extract in profuse menstruation or menorrhagia where there is no serious mucous membrane lesion or tumor growth is often of marked advantage, especially in menorrhagia of your girls.

6. How frequently ergot is of value in these cases of asthma I am not ready to state, but I have had several cases in which I obtained marked benefit from its use, more than with bromides, or ordinary doses of morphine. There are two types of asthmatic attacks, in one of which nitroglycerin or vasodilators are of the greatest advantage, and another type in which the same marked advantage can be obtained from suprarenal in some form, this during the paroxysm. Other types of asthma, and I am not going into the etiological cause, which, of course, must be removed, whether it be nasal polypi or the reflex, where there is more or less persistent wheezing or frequently recurring, almost nightly, attacks, that ergot has seemed to me of marked benefit.

7. Most cases of Graves's disease, with its lowered blood tension, hot flashes, profuse sweating, increased nervousness, and sleeplessness are benefited by ergot; of course not to the exclusion of such drugs as strophanthus, perhaps bromides, thyroidectin, or other antithyroid serum, combined with rest of mind and body, and a diminished meat diet. Ergot is also of benefit in all cases of hysterical excitement, more I believe than all the so-called antispasmodics, except possibly the lime and soda glycerophosphates which also seem to inhibit and quiet thyroid activity. Of course, ergot should not ordinarily be given during the menstrual epoch.

8. As a corollary to the last indication and to its indication in cerebral irritability and inflammation is the use of ergot in drug habits. It certainly aids in a more rapid diminution of the drug and the final withdrawal of it, and with the weak heart and cerebral excitement of delirium tremens or other forms of acute alcoholism ergot hy

podermatically is a most splendid, safe, and effective treatment. I do not say that it should be given to the exclusion of other drugs, but it is one of the most valuable.

There is one more condition in which I have used ergot successfully. I have not made this an indication because I have not had cases enough to warrant it. In fact, I have only studied one case, and that was a most inveterate diabetes insipidus in a young boy, ten years of age, whom I have had under observation for nearly two years. He came to me the most wizened up specimen of young humanity that I think I have ever seen short of an infantile atrophy case. He looked like a little old man, and the symptoms were those of a profuse volume of urine, ten to twelve quarts a day, rising from ten to twelve times at night to pass urine, vomiting, persistent headache, itching of the skin, faintness, inability to concentrate his mind upon any subject, lying around dormant or severely sick most of the time, utterly unable to play, study, or do anything. He had seen a number of physicians, and of the best, and many treatments had been tried unsuccessfully. Careful examination revealed nothing but a diabetes insipidus without any apparent cause, and no nervous lesion or injury that could be discovered. The output of urine was always greater than the measured intake. The urine was examined weekly for months, and the food measured; weighed, and analyzed. The specific gravity of these urines was sometimes even with pure water, and never more than 1,002 to 1.004. Under this careful watching and scientific laboratory investigation every treatment, except morphine and opium, were tried without success; suprarenal, thyroid, pancreas, bromide, digitalis, quinine et al.

Suffice it to say, that I was convinced it was a vasomotor affair and gave him ergot, and every time that the ergot has been stoped for observation purposes the boy has always failed to improve and has some bad symptoms develop. In a word, the ergot treatment, the amount of which given him was one half teaspoonful of the best fluid extract, four or five times a day, at first, until now he is on one-half teaspoonful twice a day, has caused his headaches to cease, his appetite to improve, and he has gained weight wonderfully, almost more weight than I wish he had. He is able to study,

and plays as usual. The amount of urine is kept down to about five quarts a day, below which I cannot bring it. He still must urinate a number of times at night, and wakes up on account of thirst. The ergot has done him nothing but good, although he has taken it nearly continuously for a year and a half. He does not show syptoms of ergotism, and if he progresses as he has done, there will be no necessity for giving it in the near future.-N. Y. Med. Journal.

THE OPEN-AIR TREATMENT OF

PNEUMONIA.

By W. P. Northrup, M. D., New York.

(Read before Am. Med. Asso.)

For more than eleven years I have been treating pneumonia patients in cool fresh air, gradually placing their beds nearer and nearer the open window. Last winter I put them out on the roof. What I have to say about the beneficial effects of open-air treatment is founded mainly on last year's experience at the Presbyterian hospital. In all months of the winter it was. our systematic practice to put all pneumonia. cases for six hours of the day on the roof, in the open air, in all weather, except high harsh winds, rain or snow. Indeed, the patients were not always brought in for little rains or snow falls, and many times were out when high snow banks formed a corral about the space in which the beds were grouped. A permanent wind-break, formed by the sun room on the west, and a built up screen on the north, protected them somewhat. Much of the time, however, the wind was in the south, and more often in the east. In this case a very inefficient canvas awning partially screened the patients, until one night in December high winds wrecked the canvas.

"The practice of placing severely sick pneumonia patients in the open air in midwinter was not adopted without much observation and some self- education. Gradually, after most careful precautions and constant watching, it became the firm conviction of all observers that such patients were decidedly benefited thereby. At last it was decided upon as a routine treatment.

"No one is convinced by another's experiI am not going to convince anyone

ence.

that he should adopt the routine treatment. I am only attempting to get some few to try it for themselves. If it seems to them to give a very sick patient the best chance for life, the method will survive criticism and be adopted. If it does not, it will deservedly fail.

"We wish to support the patient in the fight, to give the blood, the organs and the body cells every aid in our power to counteract the deleterious effects of the infecting agent. I would not underestimate drugs, I would only magnify the therapeutic value of hygienic measures, especially water and fresh air. I would say that the two most important aids are plenty of water, inside and outside, and fresh air everywhere."

Dr. Northrup went on to illustrate his theory with the case of a little girl of three years, who came into the Presbyterian hospital with lobar pneumonia, one large lower lobe being solid. From indications in the mouth the house physician suspected measles, and the child was moved temporarily into a small room with a screen bent around the bed. The child's fever immediately rose, it became delirious and dusky in the face, but on being taken to the roof it soon fell into a quiet sleep. Shortly after its arrival there the mother came to see it, and was horrified to find her child on the roof in the cold east wind, but she was forced to admit that the child looked and seemed better, and she became quite reconciled to the treatment.

Another example was a boy of six who developed a double broncho-pneumonia after a serious operation for foreign body in the œsophagus. This child was so desperately sick that the staff considered it could not live three days, no matter what was done for it, but on being put on the roof for six hours a day it recovered. Dr. Northrup said: "I truly do not believe that this case would have recovered under old ward conditions, and constant rest in the same air and environment. As I said at the outset, I expect no one to be convinced by this paper. I only hope someone will be induced to try the treatment. Begin with a case so bad you believe it has no chance for life. If they show no improvement when entirely surrounded with cold, streaming fresh air, then I have nothing to sav."

"To summarize:

"1. The cases most favorably affected by open-air treatment are those with severe poisoning, with delirium, partial cyanosis or deep stupor ('dopey'). In my experience all cases fare better in cool fresh air. Open air may be secured by screening off the bed and a portion of the room next to the window.

"2. In my experience no cases of pneumonia have been injured, and a few have been much aided, possibly saved, by the cold fresh-air treatment.

"3. If pneumonia due to an infecting agency is benefited by the treatment, one may be easily led to try it for other infectious diseases. As a matter of fact I have tried it for many others, including typhoid with severe bronchitis, whooping cough with bronchitis and convulsions, with excellent results. It seems to me the ideal treatment for all forms of 'septic fever.'

4. The only regulation is to make the patients comfortable, keeping their feet warm especially. The ears, nose and hands may get cold without harm.

"Finally-The Presbyterian hospital is so convinced of the permanent usefulness of open-air treatment for all infectious fevers, that it has built a roof garden for the children's ward, and is about to build on the main roof of the medical side of the hospital a colossal roof garden. One-half of this has a "horse shed" structure, the shed open at the south, and a liberal space in front, enclosed, like a paddock, for a roof garden. In bad weather the beds of the fever patients are to be wheeled back into the depths of the shed. In good weather they will be advanced more and more to the opening, or even out into the garden. They will remain there night and day, so long as their fever is high. It is to be an open-air ward."-Med. Review of Reviews.

In cases of chronic appendicitis, if an examination be conducted with the patient in a hot bath (150° F.), the thickened appendix may often be felt to roll under the finger.-American Journal of Surgery.

Gradually increasing hoarseness in people past middle age, without definite cause, and with a history of pain radiating to the ear, is suggestive of malignancy.-American Journal of Surgery.

THE VALUE OF THE COUNTY SOCIETY.

A Symposium in the Wayne County, Mich., Society.

Value of the County Society to the Older Practitioner.

Leartus Connor, M. D., Detroit.

For the purposes of this discussion, we shall define the older practitioner as one firmly established, able to earn his living and save a comfortable surplus. He is neither a past nor coming practitioner but a present one-the present one. He has graduated from the class of younger practitioners and is a candidate for the oldest one so is free from both the friskiness of the former and the fixedness of the latter.

It is well for us to agree on what constitutes a County Medical Society.

I. It is not a medical club-black balls are no part of the county society-only the majority voting in open meeting prevents the admission of applicants for membership. In their place medical clubs are of great value, but they are no part of a county medical society.

2. It is not "a holier than thou society"its membership does not claim a past without faults, a spotless present, or a monopoly on all virtues of the future. Such immaculate (in their own esteem) societies have been and still are since Pharisees linger on the earth.

3. It is a society of the entire medical profession in a county. If individuals fail of being reputable, it seeks to place about. such the conditions for becoming reputable, and when the process is fairly started, takes them into membership. So long as a single legally qualified physician, within the limits of a county society, is without its membership, so long the Executive Committee has work undone.

The question now fairly before us is "what value has a county medical society to the older practitioner ?"

We shall assume that the type of which we speak is well educated generally, as well as professionally, that he is fair minded, and seeks to do his best for patients, fellow practitioners and the people, and