of the same subject corresponding respectively to the "passive phase" and the "active phase" of Wright's "opsonic index.” 10. The activities of the cytogenic system, leading to an increase in the number of blood corpuscles and a stimulus to the activities of the individual corpuscles; and through these to completed protein assimilation and immunization, are governed in part by hormonic stimuli; the internal secretions actively engaged including those of the adreno-thyroid system and secretion from the duodenum. 11. The cytogenic system (including the bone marrow, the spleen, and the lymphatic glands) is a highly important member of the endocrinous system; the detached blood corpuscles are to be regarded as still a part of that system; and the study of the system as a whole offers a fruitful field for discovery of new methods in immunization and the treatment of infectious diseases. 12. The general theory of the action of the cytogenic system above outlined finds support in clinical observations of disease and in empirical therapy; and the theory itself gives important clues to the scientific measures, including an extention of serum-therapy and vaccine-therapy and the development of a new cyto-therapy. Such, then, are some of the salient aspects of the Proteomorphic theory of immunization; a theory which postulates the cytogenic system as the chief immunizing mechanism, and its daughter cells, the leucocytes and red corpuscles, as the active direct agents in carrying out the beneficent functions of that mechanism. It is not claimed that a complete demonstration of the truth of this theory in all its aspects has been presented, nor that such demonstration is possible with data at present available. Nor can it be supposed that all parts of so novel a theory have been correctly conceived. Yet, even as presented, it would appear that the theory throws light into a good many dark places of the realms of physiology and pathology. In any event, we feel that the fundamental concept of the theory has been made sufficiently plausible to justify, and indeed to demand, a far larger share of attention for the leucocyte and the red corpuscle on the part of bacteriologist, pathologist, and practicing physician than has hitherto been accorded these small but highly important bodies. PEDIATRICS ORIGINAL ARTICLES A DISCUSSION OF SOME FACTORS OF DISORDERS OF INTERNAL SECRETION IN CHILDREN* BY TOM A. WILLIAMS, M.B., C.M., EDIN. Ex-President Washington Society of Nervous and Mental Diseases; Corresponding Member Soc, de Nural., Paris, Etc.; Neurologist to Ephiphany Dispensary and Freedmen's Hospital Washington, D. C. Although it is sometimes stated that no matter what gland product is given a backward child, there will be improvement in growth and mentality, whether the diagnosis is hypothyroidia or the adipose-genital syndrome, yet it will be dangerous to generalize from the few instances hitherto on record. For it must not be forgotten that the thyroid and lymphoids have some functions in common, and hence confusion between the two syndromes caused by their respective deficiency is apt to occur. Thus, I have now under observation a woman, thought to be myxedematous by so good an observer as Osler 12 years ago, the progress of whose case shows a dyspituitarism so distinct as to give the picture of acromegaly, consisting of mandibular enlargement with prognathism, enlargement of the hands and feet-the latter by a size and a half-adipose with paresthesia, characteristic central headache, asthenia, and attacks such as described by Marks under the heading "Aeromegalic State." Such confusion regarding children must be very difficult to avoid; and the explanation of an error of diagnosis should be first excluded before we venture to infer that it is a matter of indifference whether we prescribe gland products so different as iodothyrin, chromafin, extractine, and posterior pitui tary substance, even though we do admit the great power of such products as stimulants to growth. Concerning the thyroid juice, we have to remember that *Remarks made before Pa. State Med. Assn., Sept.. 1914. its chief function seems to be activation of chemical reactions already prepared, rather than an actual participation in the metabolic equation. The hypothyroid child is merely sluggish, not idiotic or demented, the physiological processes are not changed in kind, but merely retarded. Even growth is not permanently arrested; and the proof of this is that thyroid. feeding completely changes the clinical picture. Likewise, when the thyroid secretion is in excess, there is merely a speeding of the machine and its chemistry. It would seem that only when the speeding up preponderates upon some definite ogran which can pervert function is there produced anything more than a hypermetabolism. For instance, the nymphomanic type of reaction so often seen in hyper thyroidism cannot be due to that directly, but may be due to the increased labilisection of the ovarian secretion caused by the thyroid juice. I say "may be" for we must take into account also the psychological determinants of sexual desire; and this will only be done when a series of proper analyses are made in such cases of hypo-thyroid nym phomania by men trained to weigh both the bodily and psychical factors in such cases. I say this because of some experiences which indicate very strongly that the etiology of some cases of hyperthyroidism is in the main psychological; and also on account of the fact that states of fear, shame, and anxiety which produce thyroid hyper-activation often have to do with psychologica! situations concerning the productive function. But, because of the diffusion of the thyroid juice throughout the circulating fluids, it must be remembered that this juice is ready to activate at once any organ whatever which happens to be extraneously stimulated at the moment. According, as the stimuli to reproductive activity are very abundant in community life, it is possible that the primitive factor of a psycho-sexual disorder may have to be sought for in an initial thyroid hyperactivation caused by a chemical agent, such as a toxin absorbed from the mucous membrane of the respiratory or digestive apparatus. The question can only be settled by the very careful analysis, both physical and psychical, of many cases. For instance, a woman of 28 with hyperthyroidism, show ing hyperplasia and eye-signs, was referred to me for psychological treatment, could trace back characteristic psychological reactions to the age of 13, and associates them with the tremendous mental tension and anxious emotion created by constant friction between her father and mother. To attribute far-reaching and profound disorders to a tight prepuce, a deviated nasal septum, or errors of refraction or similar abnormalities supposed naively to create disturb ances reflexly, is unworthy of the medicine of this day. Of course, I am not alluding here to instances where refractive error causes so much extra effort as to overload, or where a twisted septum creates respiratory difficulties or venoustasis, or where proper cleanliness is not secured because of a tight prepuce. None of these mechanisms is reflex, and all definitely demand interference. What I am referring to is the looseness with which the word reflex is impounded to serve as a cloak for ignorance of pathogenesis. 1705 N. Street, N. W. ESOPHAGEAL STRICTURE: REPORT OF A CASE* BY 1. LEDERMAN, M.D. The latter part of August, 1914, there was admitted to the Louisville Public Hospital, Miss G., aged eighteen, who had a stricture of the esophagus, said to have resulted from the swallowing of nitric acid. Dr. G. C. Hall was at that time in charge of the service, but I was called to examine the patient. during his absence from the city, and found a stricture in the aortic portion of the esophagus, i.e., the location corresponded to the manubrium sterni. However, this had been determined. before I saw the patient by the X-ray and bismuth test, therefore the results obtained by the two examinations exactly coincided. A few days later Dr Hall returned and assumed charge of the case. I believe he experienced considerable difficulty in passing esophageal bougies of any size; at that time the girl could swallow only fluids with difficulty; the liquid merely trickled through the small opening; she was unable to swallow any semi-solid food. It was deemed advisable by Dr. Hall and the surgeon in charge that a gastrostomy should be performed. *Clinical report before the Society of Physicians and Surgeons, Louisville, Ky., November, 1914. After the patient had been anesthetized and by the aid of esophagoscopy alligator forceps were passed through the stricture. The gastrostomy assisted in demonstrating that it was not a false passage. Dilatation was then practiced with bougies up to No. 24 French sale. The girl in the meantime was fed through the gastrostomy opening; she gained in weight and improved in health. When I went on duty at the hospital, October 1, 1914, probably ten days had elapsed before an attempt was made to pass a bougie. At that time it was found absolutely impossible to introduce a bougie of any size through the stricture which seemed again to have become impassible. After several futile attempts the girl was again anesthetized. Esophagoscopic examination was unsatisfactory without anesthesia as the parts were so extremely sensitive, although I had experienced no trouble upon the first occasion. Local anesthesia did not suffice to overcome the intense straining and gagging. When the patient was placed under general anesthesia, October 12, it was readily demonstrated that the stricture had contracted to apparently its normal caliber. As no bougie could be made to enter the small passage, the alligator forceps were again used in the same manner that Dr. Hall had done previously, and the opening enlarged in this way until a bougie could be easily introduced. In dilatation I used a moderately flexible bougie which it was found could be passed without trouble, whereas a soft rubber tube could not. Before the patient left the operating table I succeeded in introducing a No. 24 F. esophageal bougie, but nothing larger. Since October 12 dilatation of the esophagus has been practiced twice weekly, the size of the bougie being gradually increased. A No. 40 French bougie can now be passed with practically no difficulty. The gastrostomy wound has been allowed to close spontaneously and is giving no trouble. The girl is now able to eat anything she wants, and swallows anything that can pass through the normal esophagus. Until two weeks ago she was unable to swallow meat, but has no difficulty in doing so at this time. She has regained much of her lost flesh, and has left the hospital with the understanding that treatment is to be continued indefinitely. The usual history of these cases is that the passage of bougies is required for a long time, it may be a year or even |