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a welcome aid, is not essential; no powerful thera-peutic measure, such as cold bathing, should beused with the treatment, which is as specific forpneumonia as quinine is for malaria. The dia-

gnosis of Mr. Mathison’s cases seems to have beenmade on the symptoms and physical signs theypresented, without the aid of bacteriology. Thesimplicity of the treatment he recommends is noless striking than the success with which it wouldseem to have met in his hands and in the hands ofother medical practitioners he names; a modernTertullian might even be tempted to say of it,Credo quia absurdum.

AN EDUCATIONAL LUNCH-ROOM.

A VERY interesting experiment which at thepresent time might well be tried in this countryhas recently been started by the Department ofHealth in New York. An educational lunch-roomhas been opened for the use of the employees of thedepartment, the object of which is primarily to

provide a wholesome luncheon at cost price,and secondarily to educate the patrons in the

subject of food and nutrition. From a copyof a specimen menu which we have receivedsome idea is obtained of the luncheon served andof the methods followed to educate the customersin all questions relating to food values. This

programme is divided into five columns. Firstis given. the name of the dish, then the price,then the quantity, next the calorific value,and finally the protein content. A few examplesare as follows: 4 oz. of lean beef are provided,costing 20 cents, the calorific value of whichis 140 and the protein value 30; an averagehelping of potatoes, costing 5 cents, gives 150calories and 4 grammes of protein; 3 oz. of ham,costing 15 cents, give 260 calories and 20grammes of protein, and so on. These specimenmeals show at once the foods which do or do notsupply a sufficiency of calories or proteins, and themost economical way therefore in which each canbe obtained. The experiment will be watched withinterest, and though progress may possibly be slowyet the subject is more likely to be appreciated bythis objective teaching of the lunch-room with itsscientific menu or " food wisdom " notes than inany other way.

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GASTRIC HEADACHE.

THE condition popularly known as " sick head-ache " or " bilious headache " has received littleattention. Probably because the attacks are transientand do not endanger life or injure health it is

regarded as one of those minor ailments scarcelyworthy of the investigator. Yet it is a verycommon affection, and, as those who suffer from itwell know, a most distressing and at times dis-abling one. In the American Journal of theMed’ical Sciences for May Dr. W. F. Cheney hasbrought forward evidence that at least one form ofheadache, probably known as " sick headache," isdue to gastric disorder. This affection he terms"gastric headache." The symptoms are wellcharacterised. The headaches are usually periodic,and may occur but once in a month or a

week. They usually come on while the patientis in good health and are of variable duration,but rarely last more than 24 hours. He mayawaken with the pain in the morning, which growsworse as the day goes on, or it may come on inthe evening, persist during the night, and wear

off after he rises. The pain may take theform of hemicrania or involve the whole head.Sometimes nausea and vomiting accompany thepain, giving rise to the term " sick headache," butin other cases no gastric disturbance is even sus.pected. On the other hand, there may be evi-dence of gastric disorder, such as belchingor water-brash, or a sense of distension after-meals, an abnormal appetite, or a persistentsour taste in the mouth. In a third group habitualindigestion of the hyperchlorhydria, atony, or

chronic gastritis type is complained of. At thetimes of the headache the gastric symptoms areintensified. Dr. Cheney has investigated the gastric-functions by means of test meals and found that.the most frequent disturbance is loss of gastricmotility. Gastric secretion may or may not be

normal, but the important fact is delay of food inthe stomach. If patients with this abnormalityindulge in an unusually heavy meal or eat whentired or exhausted by mental or physical exeitionheadache is likely to result. The following is ajiexample. A well-nourished man, aged 40 years, hadsuffered from headaches for seven or eight years..At first they occurred about once a week, butrecently as often as every second or third day.Nausea usually accompanied headache, but rarelyvomiting. The appetite was poor and much gas was.belched after eating. Physical examination wasnega.tive, but after the Ewald test meal the total amountof stomach contents obtained was large, 176 c.c.,and even after its removal a loud splash could beelicited. The total acidity was 72, with free HCl 3&and combined HCl 20. On inflation the greater-curvature was found 4 cm. below the navel, butthere was no peristaltic wave. The diagnosis was.atony with hyperchlorhydria. A soft non-irritating-diet with restriction of acid and highly seasonedfoods was advised, and nux vomica was given aftermeals. As the patient spent long hours in anoffice he was urged to take more exercise out ofdoors. The headaches practically disappeared and.recurred only at long intervals after an indiscretionin diet or work. Dr. Cheney does not suggest howthe loss of gastric motility produces headache.The explanation seems to be that it leads to theformation of some toxins which are absorbed intothe system. The foul tongue and breath-whichmay be observed in these cases and which he does.not mention-point to this. He says that constipa-tion is frequently present, but the condition is,commonly observed in a most severe form withoutany constipation. However, a purgative, especiallyone which is an intestinal disinfectant, such ascalomel, seems to shorten the attacks. Dr. Cheneyhas shown that these headaches are often dueto gastric disorder, but we would suggest that thetoxaemia on which they depend may also be due tosome intestinal disturbance, or even to hepatictrouble-to revert to the old view.

THE NODAL OR A.-V. RHYTHM.

BY nodal rhythm there is meant synchronous or-almost synchronous contractions of the auriclesand ventricles. Instead of the latter succeeding theauricular systole at an interval of 0’12 to 0’16 second.the two chambers contract together, due to theexcitatory impulse reaching both chambers at thesame time. This impulse originates at the A.-V.node, situated at the upper end of the bundleof His and equidistant, functionally, from eachchamber. Such a dislocation of the

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pacemaker "

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of the heart from its normal site the sinus, to thissecondary and less rhythmic centre was thought atone time to be distinctly rare. But this opinion isnow less strongly held since graphic methods of exa-mination allow of its recognition. It gives rise to nosymptoms, it does not influence rate, and for thesereasons no doubt is less often recognised thanwould otherwise be the case. There are two con-ditions which may induce it. One is where thesinal rhythm is so slowed that this less rhythmicsecondary centre is allowed the opportunity of

initiating its otherwise dormant rhythm. The otheris where the nodal rhythmic activity is enhancedin proportion to that of the sinus. Instances ofboth these kinds are known. In a recent issueof Heart Dr. E. E. Laslett reports one wherethe nodal rhythm is provoked through sinalslowing. Its rate was 53 to 59 per minute.

Examples of heightened nodal rhythm replacingthe sinus have been recorded by Cowan, andin several of his cases microscopical examina-tion showed definite inflammatory changes involvingthe nodal tissue. Another case has been reported(Lea) where similar increased nodal activityoccurred. In this case, however, its rhythmic rateso closely approximated to that of the sinus that theslight changes of sinal rate due to respiration, aquickening in inspiration and slowing in expiration,resulted in alternate phases of sinal and nodal

rhythm, sinal (normal) rhythm occurring duringinspiration, nodal rhythm during expiration. Thenodal rhythm may not be without practical interest,in spite of its offering no subjective symptoms,since it has also been shown that phases of thischaracter may occur at certain stages of chloroformanaesthesia. These latter observations have, at themoment, been confined to animals only, but theirsignificance remains to be estimated clinically.

THE ETIOLOGICAL FACTOR IN CEREBRO-SPINALFEVER.

IN another column we publish an article byDr. R. Donaldson under the title of "A Contributionto the Study of the Etiological Factor in So-calledCerebro-spinal Fever." He makes various observa-tions in regard to the bacteriology of cerebro-spinalfever which are not in accordance with the viewsgenerally held, but which are certainly suggestive,and if corroborated by other observers wouldnecessitate considerable modifications of the

opinions hitherto set forth as to the etiologyand nature of the disease. Dr. Donaldson’sobservations were made during the outbreak ofcerebro-spinal fever in Reading, and he examinedthe cerebro-spinal fluid in about 60 cases, so

that his experience is considerable. At the out-break of the disease he believed, like many others,that the meningococcus of Weichselbaum was re-sponsible for the disease, but he now enunciates anew theory. He relates two cases, one of pyaemiawith a history of preceding gastro-intestinal disturb-ance followed by a prolonged illness, and a second,which, while showing symptoms of meningococcalinfection, might have been attributed to middle-eardisease followed by an abscess in the brain. Fromeach of these cases similar organisms were isolated.Dr. Donaldson then proceeds to state that in all thefluids and purulent exudates from cases of cerebro-spinal meningitis which he examined he observedone common factor-namely, the presence of

diphtheroid rods, together with Gram-positive andGram-negative diplococci ; all the various types ofform were reproduced in cultures from the two

cases to which we have just referred, and hetherefore concludes that they were due to the sameinfective agent as was responsible for the epidemicthat occurred in Reading. After a full descriptionof the cultural characters of the organisms, theirmorphology and staining reactions, and the resultsobtained by inoculations in animals, the conclusionis arrived at that the causal organism of theepidemic dealt with was a diphtheroid rod

closely related to the Klebs-Läffler bacillus. Thisrod appeared as a pleomorphous organism,which might give rise to Hoffmann-like forms, to.what appear to be meningococci, &c. He maintainsthat this organism is very widely spread in naturein one of its most resistant forms, and " it is thisform and not the meningococcal one which is.transmitted from one to another." Dr. Donaldson’s.propositions deserve careful study, but we considerthat further observations are necessary and hopethat other bacteriologists may be stimulated, as.

opportunity arises, to investigate along theselines. The suggestion that the struggle of a newdisease to win a place among epidemics is.

being witnessed requires further evidence beforeit can be accepted, but Dr. Donaldson has.certainly given sufficient cause for attention andinvestigation. ____

ALKAPTONURIA, WASSERMANN’S REACTION,AND OSTITIS DEFORMANS ALKAPTONURICA.

IN a lengthy article of 130 pages illustrated with19 reproductions of skiagrams and numerous curvesand figures, Dr. G. Soderbergh gives a new clinicalaccount of the four cases of alkaptonuria hithertodescribed in Sweden, drawing particular attentionto the fact that alkaptonuria without a previoussyphilitic infection may give rise to a positiveWassermann reaction, and to a chronic deformingarthritis in many ways comparable to Paget’sdisease of the bones and joints. As is well known,alkaptonuria is characterised by the occurrence ofhomogentisinic acid (1-3-5-C6Hg (OH2) CH2COOH),otherwise known as dioxyphenylacetic acid, in theurine. This acid is partly endogenous in origin,or derived from the tissues, and partly exogenous,or derived from the proteins of the food. It isknown to have two mother-substances or pre.cursors-namely, tyrosin (1-4-CHOHCH.CHNH,COOH) and phenylalanin (C6H5CH2CHNH2COOH);if an alkaptonuric person is fed with Isevo-

rotatory phenylalanin, about 90 per cent. of thesubstance is ex.creted in the urine as homo-

gentisinic acid. The disorder is known to be verychronic, mainly affecting males, and to be familialin incidence. Time was when alkaptonuria was.regarded as a harmless type of abnormal meta-bolism, a metabolic

"

sport," as breeders might say.Soderbergh, however, lays stress on the trouble-some and pathological associations it may havewith the very rare disease ochronosis which oftencomplicates its later stages, with the chronicarthritis to which Allard and Gross drew attentionin 1909, with the cardio-vascular disease empha-sised by Kolaczek in 1910, and with the occurrenceof a positive Wassermann reaction in the blood.He gives a full account of the four Swedish casesof alkaptonuria with ochronosis, one of them a newcase of his own. This patient, a peasant aged 42,exhibited a round kyphosis and rigidity of the wholedorsal and upper lumbar spinal column, thickeningof the spine of the right scapula with waviness of

Zur Klinik der Alkaptonurie, Nordiskt med. Arkiv, Stockholm,1915, Inre Medicin, xlviii., Hft. 4, No. 19.