are constantly complaining because so little attention is given to the warning and to the request of such a large and intelligent part of the public as our medical fraternity. Is it not for this very reason, namely that the physicians themselves do not act as a unit and do not take, as a rule, any interest whatever in the ordinary course of politics? This being the case, from the standpoint of the politician, they can have no weight. From the standpoint of the public, a large portion of which is organized and managed by the politician, it cannot compel a following. It does seem that the solution of the situation is comparatively simple. The physicians themselves must follow more closely, not only what affects them, but also whatever is of interest to their own municipality. In short, they must identify themselves at the outset with what appears to them to be the measures most intelligent and best adapted to the needs of the community at large; and they must do this, not to the injury of their professional work, nor to the loss of opportunity to increase their professional information. On the other hand, the public must come to view such a changed relation in a very different light from that in which it now does. It must realize that an important factor for good has entered into political life. It must appreciate that in so doing this factor loses none of its claims to the respect and confidence of individuals in the special work to which its life is dedicated. The gist of the whole matter is simply this, that in a republic it is incumbent upon every citizen to be a politician.

RECENT REGULATIONS TO PREVENT THE SPREAD OF PULMONARY

TUBERCULOSIS.

The Health Board of New York city, which is ever thoughtful and provident for the health of the community in general and its own bailiwick in particular, has stirred up a considerable amount of discussion by the profession as well as by the laity, as the result of the latest recommendations which they have succeeded in having appoved, advising an amendment to the sanitary code declaring that tuberculosis be officially considered a communicable disease, etc. (We print elsewhere the communication on the subject.) Every week a new writer complains to one or more of the medical journals of some disagreeable feature which would result from such an enactment. The latest complaint was because the family were given minute instructions by the Board of Health in regard to the disposal of the dead body, in a case, which, at the worst, could have been only in a very early stage of phthisis. The communicability of consumption has been established beyond a doubt, but the uncertain and not always accurate pathological examinations do not enable us to diagnose with certainty. every case of the disease. But granting that such a diagnosis be possible, a vigorous protest is apt to be entered by private patients, especially in

early stages of phthisis, against having their names entered upon the Board of Health register as sources of communicable disease. On the other hand, the physicians themselves are apt to take more personal interest in the prevention of the dissemination of tuberculosis by their patients, and in order to do so they must inform themselves, as well as their patients, in regard to the means to be pursued. We believe that an immense amount of good will be accomplished by the recommendations, in that it will compel the physicians to inform themselves fully in regard to the most modern methods for the prevention of the spread of tuberculosis; but we question both the propriety and the right of the Health Board, or any other board, to compel such information as they propose to demand from the physicians respecting every case of phthisis. Fortunately for the profession in New York city, the board consists of a number of most intelligent and able, active practitioners, and whatever legislation emanates from it affects the interests of the individual members of the board equally with those of every practitioner in this city. This is, doubtless, the reason there has always been such a cordial relation between the profession and this part of the public service. The board has always shown itself ready and willing to assist, not only the public, but its professional brethren in whatever seemed to contribute either to good of the public at large or to the individual patient; and this is why we are not a little anxious in regard to this most recent proposition.

ACTION OF THE MED. ASSOC. OF THE DISTRICT OF COLUMBIA.

Apropos of our editorial last month on the abuse of medical charity the following recommendations, adopted by the Medical Association of the District of Columbia, February 16, 1897, will be of interest to the profession, as well as a guide in the matters upon which they touch:

I. That every institution for medical charity shall require from every applicant for relief in a Hospital or Dispensary a written certificate to be obtained as hereinafter provided. Emergency cases are to be excepted from the operation of this rule.

II. That such certificate be obtained from Physicians to the Poor, the Board of Associated Charities and any registered physician.

III. That cases of sick and injured persons found upon the streets, in the stations or elsewhere, who require immediate treatment shall be carried to the Emergency Hospital, or the nearest Hospital having an Emergency Service, or to their homes, if so directed by the patient or his. friends.

IV. That Emergency Patients shall not be detained longer in such Institutions than the necessity of the case imperatively demands, but

shall be discharged from the service and sent to their homes or to some public hospital as the patient may elect.

V. That members of this Association shall be entitled to the privilege of attending private patients occupying private rooms in any of the public hospitals of this city.

VI. That in future the members of the Medical Staff of Hospitals when attending medical or surgical cases in private pay-rooms shall insist upon proper payment for their services except in the case of such patients who are clearly unable to pay for same.

VII. That whenever the Medical Staff or a majority thereof of a Hospital or Dispensary resigns, and, when after due hearing, this Association finds that the resignations were for just and sufficient cause, it shall be forbidden for any member of this Association to accept a position on the Staff of said Hospital or Dispensary.

VIII. That whenever one or more members of the Medical Staff of a Hospital or Dispensary are dismissed, and when after due investigation this Association finds that such dismissal was without just and sufficient cause, it shall be forbidden for any member of this Association to fill the vacancy created thereby.

IX. That complaints made under Rules VII. and VIII. shall be made in writing to the Standing Committee, which, after due consideration, shall report its findings to the Association.

J. R. WELLINGTON, M.D.,

Secretary.

W. P. CARR, M.D.,

President.

We shall have occasion later to consider separately some of these recommendations.

By J. ALLISON HODGES, M.D., Richmond, Va.,

Professor of Nervous and Mental Diseases, University College of Medicine,
Richmond, Va.

From whatever standpoint viewed, tubercular meningitis is a most interesting disease.

The consideration of its bacillary origin, its peculiar mode of invasion, its stubborn resistance to all known therapeutic measures, its appalling record of mortality being the most directly fatal of any disease of early childhood; either or all are questions inviting the interest and enthusiasm of every student of disease.

It may almost be called an incurable disease; for, notwithstanding three cases of its happy termination are reported, it is not at all improbable that an incorrect diagnosis was a source of error even with those distinguished clinicians.

Discarding for the present other interesting and instructive features, I desire especially to direct attention to its diagnosis, for I consider this of paramount importance, in not so much that its fatal termination can be avoided, as it is at present treated, but that the ends of scientific exactness in this as in other diseases may be attained, and that future errors of prognosis may be avoided.

I am persuaded from personal practice, and from my experience as consultant, that many cases of this disease have been incorrectly interpreted by the attending physician, and the significance of many of its varied symptoms overlooked, until its unfortunate termination revealed

* Read before the Richmond Academy of Medicine and Surgery, January 26, 1897.

MY B'UD

the correct nature of the illness. A melancholy experience with two such cases is a lesson still indelibly impressed upon my mind, and it was this that first attracted my attention to my lamentable error in diagnosis; for, deceived by the mild train of symptoms before coma supervened, I overlooked the danger that was impending, and gave an encouraging prognosis! When the symptoms that shall now be detailed, are considered, is it possible that others may realize that they too may have to plead guilty to such a charge of mistaken diagnosis?

Tubercular meningitis presents a preponderance of nervous symptoms, and is a distinctively bacillary disease, being peculiar to childhood, and usually attacking children between two and ten years of age. The membranes involved are the same as those in simple meningitis, but the anatomical lesions differ, for the latter affects the pia and arachnoid on the convexity of the brain, while a meningitis of tubercular character attacks those membranes at the base.

The prodromal symptoms are vague, and for this reason are apt to be misleading. As much as any clinician, I abhor the division of any disease into arbitrary stages, being well aware how variable are the manifestations, but for the sake of clearness, I prefer to so divide the symptoms of this disease; for, as a rule, there is a regular sequence in them; and it is only from a contemplation of this succession of symptoms, when associated with other manifestations, that the cause of the ominous changes which occur in the later periods is suspected and can be diagnosed.

I believe that too great importance cannot be attached to the mode of invasion of this disease as a diagnostic point. In simple meningitis there is a stormy onset, and a convulsion ushers in the scene, while in tubercular meningitis the convulsion is usually one of the last acts in the sad drama. In tubercular meningitis, this period of invasion is so peculiar that it cannot be mistaken by the careful observer, if the facts which are of such import in the determination of this particular disease are faithfully elicited.

The initiatory symptoms are so indefinite as often to be deceptive. The child is not at once seized with a sudden illness. There is simply a gradual failing of the general health, and the only physical sign of disease is a more or less evident emaciation. This change in the condition of the child also is a variable one, being rapid and striking in some, while in others it is scarcely noticeable. In all cases, however, the emaciation at last becomes a marked feature of the case.

During the progress of the change another symptom, which may be termed a moral change, develops itself, since it is manifested in both the habits and temper of the child; for the little patient, according to its individual temperament, may exhibit all the phases and variations of its