Not so very long ago, This is a day of reconciliation. another. It is rather because one man has an enthusiasm in his work which he is able to communicate to others. This is a gift. There is such a thing as the power of some minds to create by induction in the minds of others a spirit akin to that which animates their own. It is like the electric current which is excited by the passage of the primary wave through a neighboring wire. There is a stimulus in companionship that can not be overrated, and the societies of to-day supply us with the means of acquiring this stimulus. Ours is the responsibility, if by our absence we fail to take advantage of such an opportunity. Ours the responsibility if, attending, we fail to participate in the discussions of our fellow-workers. It seems to me a pity in this connection that the plan for a society building in Brooklyn at present languishes. No one thing done in this city at present would more advance the cause of scientific medicine than the erection of a proper home for the county society, in which all the special societies could find shelter. What inducement is there at present for us to immure ourselves for an hour or two in a stuffy, ill-ventilated den more fit for the assembling of a boys' debating club than the meeting place of a learned society with over five hundred members? I can not but regret in this connection that the unfortunate differences of years ago | keep from us not only the presence but the support and contributions of a large number of gentlemen who ought to be in our ranks. Modern medicine ought to be broad enough to admit of different views on many sub-ating have all been improved. By rational and humane jects without there being a sufficient cause for a separation of the medical profession into two camps. Such a separation must inevitably weaken, has weakened, the influence of the profession. Our business is to cure disease, and we ought not to waste our time and energies and divide our forces on subjects which can now certainly be left to the individual conscience. What the state recognizes as legal we must recognize, if we would be good citizens. At the present juncture of affairs in this city it seems a great pity that this division in our ranks should persist when, for the advancement of the science to which we are all devoted, we need united effort. In a great city like Brooklyn no society can really flourish without a permanent home worthy of the profession. Libraries must be properly housed and in a position where the books can be consulted readily and pleasantly. At present we are at an absolute standstill in this matter. For the advancement of science, for the unification of the profession, is it not possible for us to arrive at a modus vivendi in which we can all live at peace and join our forces, and so carry to completion that building in which we are all interested? I hope that this will not be considered an inopportune digression. I regard the assembling of ourselves together in the various societies and in the parent society as one of the opportunities of modern medicine, and it is a responsibility laid upon us in this city to provide a suitable place of assemblage. In a general way, I have thus far indicated what in my judgment constitute our opportunities in a broad sense, and have outlined the responsibilities which the opportunities of journalism and the medical societies have laid upon us. The distinguishing character of the work of the past few years has been in the line of rendering medicine more nearly an exact science. Our means of diagnosis, our therapeusis, our methods of oper experiments on animals new operations and new remedies have been proved and placed on a firm foundation. It may be of advantage to recall a few of the newer methods to your notice. The youthful science of bacteriology has rendered the greatest assistance to diagnostic medicine, and goes hand in hand with the companion science of pathology, of which it is indeed but a part, rather than a distinct science. With the aid of the bacteriologists we are able to make a far earlier diagnosis of the infection of the human organism by the tubercle bacillus than has before been possible. I remember a striking instance of this in my own experience. Some years ago, when working in the bacteriological department of the Hoagland Laboratory, a specimen of sputum was brought to me for examination. This was in September. I examined for tubercle and found the bacilli in great numbers. The gentleman who brought me the specimen, on my making the report, said to me: "Doctor, do you know that in the late spring, Dr. X., of New York (mentioning a name that was then a household word) examined this lady's chest and pronounced her case one of chronic bronchitis?" There was not at the time a better physical diagnostician in the country than the gentleman who made this diagnosis, and yet I am convinced that an examination of the sputum made at that time would have revealed the true nature of the disease. If there is a stage when consumption is curable it is in idiopathic. There can no more be an idiopathic disease than there can be idiopathic weeds. As spring weeds from seeds sown by the wind in garden soil, so from various intruding organisms come most of the diseases to which the body is heir, except the scleroses, and these are degenerative changes. Every year removes some disease from the terra incognita of speculation to the certainty which rests on proof. Take, for instance, pneumonia and epidemic cerebrospinal meningitis. We know that both diseases are the result of the growth of the Bacillus lanceolatus, in one case in the lungs, in the other in the meninges of the brain and spinal cord. So in many ways is medicine becoming an exact science, and this is due in large measure to the work of the laboratories, aided by the clinical observation and records of acute minds and the employment of exact means of diagnosis such as have been indicated. Modern methods have done much to clear up the conditions of the blood in certain diseases. We have such instruments of precision at our disposal as Gowers's or the Abbé-Zeiss disc counter and the hæmoglobinometer of Fleischl, and for the same purpose, in an improved and much more con its very inception. It is worse than inhuman to send patients away from home with cavities and expect them to recover. Make a diagnosis before there has been destruction of lung tissue, when there is a simple bronchial catarrh with an involvement of a few of the vesicles in the apex, and these are the cases that we may expect to save by change of climate. The great majority of phthisis cases I believe to be curable in the early stage, but this is before it is possible to make a diagnosis except by the microscope. It would be of the greatest advantage to the profession if the microscope were more generally used than it is. At present its chief use among practitioners is in the search for casts, nor is this altogether to be wondered at. At present few of the schools of medicine require a course in bacteriology, and, as few men learn more than is required of them, the graduates make no more use of the microscope than was expected of them when undergraduates in their medical school. How many errors of diagnosis might be avoided if the microscope were used as it ought to be! Take one instance the presence in the blood of the Plasmodium malaria as a symptom of the paludal fevers. I quote from a paper by Dr. Hurd, of the Johns Hopkins Hos-venient form, the apparatus of Daland, which renders the pital, which appeared in the August number of the Bulletin of the American Academy of Medicine: "If malarial influence does not depend upon the demonstrated presence of the plasmodium in the blood, it is more than probable that the condition has not a malarial origin, and some other cause should be sought for." Who of us here has not treated the onset of typhoid fever as an intermittent? How many times has deep-seated suppuration, with its chills and evening rise of temperature, been met with the exhibition of large doses of quinine! An appeal to the microscope before the administration of quinine might have prevented such errors, or at least made us more alert. The commonest diagnostic errors that are made to-day are those which confound the rises of temperature which accompany obscure tuberculous lesions and suppurations with the elevation of tempera-worthy zeal the practitioner, mindful of the intestinal ture due to an intermittent. I have made this mistake myself and have seen it repeated by far abler diagnosticians. We are not taking advantage of modern methods when we do not make it a routine procedure to examine the blood for the plasmodium prior to the administration of quinine for a paludal fever. Especially ought this to be done in a doubtful case. Failing its discovery, we ought to make further search for the cause of the febrile movement. This and this only is exact medicine. Every diagnosis which is capable of confirmation by the microscope ought not to fail of this test. One of the old evasions of medicine has fallen before the microscope and the culture tube, and that is the idea that there are any diseases which are idiopathic. We used, in the lecture of twenty years ago, to hear a good deal of idiopathic peritonitis. We now know the relation of the intestinal and other pathogenic organisms to this disease and are aware of the fact that it is never use of the microscope unnecessary. Then, with regard to the different blood elements, we have the Ehrlich stains, which enable us to distinguish between the eosinophile, or those cellular elements of the blood which show a special affinity for eosin, and the other cells. All these new methods and instruments of precision are in the line of making our work more exact. Take another set of disorders-those of digestion. A few years ago most practitioners thought they had done their full duty by a case of dyspepsia when they regulated the bowels and gave pepsin and hydrochloric acid. Whether there was an excess or a deficiency of acid in the stomach they never inquired, or to what extent the fault lay in the intestinal tract and the pancreatic secretion. We have all seen prescriptions in which with praise tract, fired a shotgun prescription into his patient in which pepsin, pancreatin, and an acid were combined. Now the intelligent observer, the reading man, the man who takes the journals and buys new books, administers a trial breakfast in a complicated case of indigestion, either that of Ewald or Leube, and tests for HCl. He is thus enabled to make a more precise diagnosis, and with exact work does not prescribe at random nor give incompatibles. In every branch of medicine there is this tendency to precision. Take the work that is being done in obstetrics nowadays. Twenty years, yes, ten years ago, the obstetrician was for the most part satisfied to let his patient fall in labor unless she was manifestly deformed, and trust to finding out that she had a narrow pelvis when the head got jammed and the necessity of interference was made manifest by the agony and fruitless labor of the patient. As a distinguished practitioner of the art said to a patient of my own not long ago, "Madam, we do not now wait until the patient gets into trouble. We anticipate that trouble and prevent it." To illustrate the truth of this remark, I mention a case from my own practice: A delicate woman came to me a year or two ago to ask whether she could safely become pregnant, as her sister had barely escaped with her life from childbirth, and she feared, therefore, for her own safety, being of slight frame. Mindful of my responsibilities, and determined to leave no means untried by which to arrive at the truth, I used the pelvimeter, and, although from a casual inspection I should have judged differently, the external measurements showed a dangerously narrow pelvis. As she was anxious to have a child, I sent her to my friend Dr. Jewett, and the verdict came back: "At term, the Cæsarean section. Possible, perhaps, to have a living child at seven months by the induction of artificial labor." Is it not probable that twenty years ago this lady would have been permitted to fall in labor at term? The general symmetry of her form was not at fault, and she was only saved from great peril by the application of modern methods too seldom resorted to by many. Yet the pelvimeter is a simple instrument to use, and if oftener appealed to would give warnings which would save poor womankind much misery and the profession some reproach. It has been said with justice in the past that medicine is an inexact science. If we would remove this reproach, it can only be by making use of the exact methods which modern medicine offers us. There are no such things as inexact processes in Nature, whether in the laws that govern the universe and keep the stars in their places or those which regulate the development of a bacillus. It is we who are inexact; and when we speak of medicine as an inexact science, it is because we are inaccurate observers, ignorant observers, erroneous in our deductions. by the Heilserum of Behring, Roux, and others. Already we are beginning to hear of cases of tetanus which yield to the appropriate antitoxine, nor will it be long before we shall be in possession of an antitoxine against suppurative and septic organisms. Time forbids that I should more than touch on so fascinating a subject as serum therapy. It promises much, and the twentieth century will doubtless see all the zymotic diseases in the same classification with small-pox, as preventible by similar methods. Skiagraphy has a future for the diagnostician both in medicine and surgery. When we recollect the crudities of Daguerre, we may expect the future to simplify the application of the X ray, and, indeed, recent observations and experiments justify this hope. Men of Brooklyn, the world is astir around us. The march of events in our profession is rapid. In our ears resounds the tramp of our neighbors' footsteps. Shall we stand still? We can not. In these days that means self-destruction, mediocrity. We must move onward. We must keep pace with the best workers in other cities. What is being done elsewhere can be done in Brooklyn, by any of us, but we must be familiar with the methods of the hour and put them to use. Nor ought we to plead ignorance of laboratory methods. I know many men, busy men, too, who have in middle life, conscious of these new factors in medicine, taken laboratory courses to familiarize themselves with the new truths. I hope to see the time, not far distant, when summer courses may be given in bacteriology and pathology and the technics of modern microscopy with the new methods and stains. In the summer time most of us have some leisure, and a summer school in laboratory practice would be of value in this city. We can not stay long behind, gentlemen, without soon lagging hopelessly in the rear. Fortunes built up on personal magnetism are becoming rarer and rarer. The people, our clients, are becoming better educated, and soon distinguish between the success which is dependent on purely personal qualities and that which is rooted in knowledge. The day of the good fellow in medicine, what with State examinations and the general raising of the standard of medical education, is, to a great extent, of the past. Mere personal magnetism can no longer gain a man success, and, as the struggle grows keener, those men in the long run will reap success who are the best qualified. In a paper of this character, necessarily short, I have been able only to indicate a very few of the advances in modern medicine which constitute the opportunity of the present. Ours is the responsibility as well as the privilege of familiarizing ourselves with the methods of to-day. The true physician is a public servant, and that man who never looks be If we survey the work of the last decade, we shall see that the development of our art has been in the direction of exact work. Speculation has given place to rational experiment; the alchemist's den, with its retorts, to the modern laboratory with its culture tube and microscopes; the search for the philosopher's stone, to researches into the origin of disease. The alchemist of the Middle Ages sought in vain for the elixir of life, but from the doors of our laboratories of this nineteenth century comes length of days to mankind. The pestilence walks in darkness no longer. The search light of science casts its rays into the depths of the night and its terror vanishes. The devastation of great epidemics, we hope, is a thing of the past, for preventive medicine now stands in the path of the destroyer, the plague is stayed and nations rejoice. Such results have been attained by patient labor, exact work, exact observa-yond his own immediate necessities, who regards the tion, exact records. Who can prophesy the future of serum therapy? That terror of childhood, well named diphtheria the destroyer, has been robbed of half its quiver of arrows profession of medicine as but a means of support, whose daily round is but a treadmill to coin dollars, will never attain the full measure of usefulness of which he is capable. There is hardly a walk in life for educated men which does not offer greater advantages for the accumulation of property than the profession of medicine. For its votaries, the science and art of healing has other and higher rewards: the ability to relieve distress and suffering, to arrest disease, to restore the dying to the arms of affection, the consciousness of doing well for others, a life well spent. Aside from the intellectual pleasure which every educated man enjoys when he is conscious of doing a high grade of intellectual work, there is or ought to be the consciousness of service to the race. After all, there is nothing in life of value to be compared to the feeling that we are doing useful work, that we are helping our fellows, and doing our part in lifting the load of misery which oppresses the human race. If our aims in life are purely personal, shadows we are, but shadows we pursue. As the Scotch lassie, Jeannie Deans, says in her appeal to the queen: "Alas! it is not when we sleep soft and wake merrily ourselves, that we think on other people's sufferings. Our hearts are waxed light within us then, and we are for righting our ain wrangs and fighting our ain battles. But when the hour of trouble comes, to the mind or to the body, and seldom may it visit your Leddyship! and when the hour of death comes, that comes to high and low, lang and late may it be yours, oh my Leddy! then it isna what we hae dune for oursels, but what we hae dune for others, that we think on maist pleasantly.” Original Communications. STAPHYLOCOCCUS-AUREUS INFECTION WITH ENDOCARDITIS after admission. Condition on Admission.-C. D., farmer, aged thirtyfour years. Frame of medium size; emaciated; skin pale, dry, and sallow. Patient tosses in bed, does not speak, though he uttered one or two sentences soon pressed; moves slightly when pricked in various parts. Protrudes tongue when chin is Pupil reflexes and motion of bulbs normal. There is an hypertrophic scar, an inch long and half an inch wide, over the lambda, without thickening or depression of the bone. is slightly enlarged; apex beat not visible nor palpable; Examination of lungs negative. The heart dullness the sounds faint, but apparently clear. Owing to the great rapidity of the heart's action auscultation is unsatisfactory. Liver dullness extends to just below the margin of the ribs. Splenic dullness enlarged; the spleen can be felt as a soft mass about an inch beyond the margin of the ribs. Examination of the rest of the abdomen negative. The urine has been passed in bed. There is diarrhoa, with frequent watery stools. The blood flows freely; it is pale and watery. The red corpuscles number 2,670,000 to the cubic millimetre; they are pale, otherwise not remarkable. Leucocytes, 45,000. Hæmoglobin (Fleischl), 50. There are no malarial parasites in fresh or stained preparations; stained with Loeffler's methylene blue; cultures not made). no pigmented leucocytes; no bacteria (in preparations Differential count of the leucocytes shows: Multinuclear, ninety-four per cent.; large uninuclear and transition forms, five per cent.; large lymphocytes, one per cent.; no eosinophiles (several covers examined). A diagnosis of pyæmia was made, the primary focus assigned to the cranium on account of the history. In the absence of localizing signs an operation was not attempted. The temperature for ten days before admission was reported as forming a double curve daily, with one paroxysm at night and one at noon. This was confirmed by careful observations, and the accompanying chart shows the remarkable features of the curve SIMULATING MALARIAL INTERMITTENT FEVER viz.: the rhythmical sequence of the paroxysms, the (DOUBLE QUOTIDIAN). BY GEORGE DOCK, A. M., M. D., PROFESSOR OF MEDICINE IN THE UNIVERSITY OF MICHIGAN. SOME time ago * I reported some cases of malignant endocarditis simulating malarial intermittent fever. I wish now to report another case interesting as a pathological curiosity, and also important as an example of a common diagnostic difficulty. abrupt rise, and complete defervescence. Both sets of paroxysms postponed irregularly. There was a severe and prolonged chill during the rise of temperature. Sweating did not occur at all. The pulse was usually between 100 and 120 in the apyrexia, rising to 180 or more in the paroxysms. At the height of the paroxysm the pulse could not be counted. The patient was fed with difficulty, sometimes refusing to swallow. Before death, the previous history of the patient was A small amount of urine was obtained. It conobscure. The most plausible of the somewhat contradic- tained a trace of albumin and a few pale granular casts. tory statements was to the effect that after one or more Early in the morning of the fourth day after admission the right arm and leg became paralyzed. The heart injuries to the head from falls the man became aphasic. became weaker. A few small hæmorrhagic spots apThe patient was sent to my colleague Dr. W. J. Herd-peared in the skin of the abdomen. The skin became man, professor of nervous diseases in the University yellowish, but the sclera were not icteric. Cyanosis of Michigan, for treatment, with a view to operating. and frequent respiration appeared in the afternoon, and Dr. Herdman, however, found that the patient had in-death occurred shortly after midnight. termittent fever and had been treated for malaria; he therefore had the patient referred to my ward. * Boston Medical and Surgical Journal, November 7, 1895. An autopsy was made ten hours after death by Dr. A. S. Warthin, demonstrator of pathological anatomy, from whose report I extract the following notes: Post-mortem Diagnosis.-Septic endocarditis (mitral valve); dilatation and hypertrophy of the heart; sep tic and anæmic infarcts of the spleen and kidneys; white thrombus of left internal carotid artery; anæmic softening of brain; parenchymatous degeneration of organs; goître. Multiple foci containing Staphylococcus pyogenes aureus. part of the left temporal lobe there is an area of degeneration. In the cortex this has a diameter of four centimetres. It extends into the internal capsule and forward into the white matter beneath the island of Reil. The tissue here is soft, in parts almost fluid, 19 10 11 4 Ꮭ 8 10 12 14 6 8 10 12 24 6 8 10 12 ? 4 6 8 10 12 2 4 6 8 10 12 4 6 8 10 12 2 L 6 8 10 122 6 8 10 12 108 105 175 180 136 135 110 112 132 154 184 140 120 120 112 138 158 140 132 120 112 140 160 172 132 124 108 121 180 140 164 136 132 116 116 148 190| 168 146 152 150,148 160 30 30 28 33 33 32 20 24 22 40 32 36 21 18 20 36 46 34 24 24 24 28 36 4421 21 20 20 48 32 32 22 20 17 16 20 48 48 44 44 42 | 52 | 42 | 40 T 100 RESP. 30 TEMP 106 105 104 103 102 101° 100 99 98 97° Temperature curve from case of endocarditis with double quotidian fever. The heavy lines indicate chills. 12 Moderate rigor mortis. Frame slender; musculature | greatly wasted; thin panniculus. The skin is slightly icteric; sclerotics plainly so. Numerous ecchymoses over thorax and abdomen. Post-mortem discolorations over back and dependent parts of limbs and genitals. Small erosions over left knee and outer side of right foot. There is slight oedema over the whole body, most marked over the lower extremities. In the median line, over vertex, there is a scar about an inch long and half an inch wide. Skullcap moderately thick; in the outer table, corresponding to location of scar, there is a slight depression. The inner table is smooth and even. Diploë very bloody. The dura is distended, slightly thickened, but not especially so in region corresponding to external scar. The superior longitudinal sinus is full of dark, fluid blood; the lateral and petrosal sinuses contain yellowish clots. Vessels of pia are greatly congested, the membrane somewhat thickened and cedematous. Through the membrane can be seen a yellowish discoloration in the cortex of the left temporal lobe with a slight depression of the surface. The pia is adherent. The pia is adherent. The meninges at base of brain are slightly thickened and oedematous; there is no exudate. The walls of the carotid arteries are slightly thickened. In the left carotid there is a firm white thrombus filling the lumen, but not firmly adherent, about a third of an inch in Icngth. The cerebral arteries are empty. In the lower yellowish-gray to dirty white in color. The lateral ventricles contain an increased amount of fluid. Other parts of the brain show no lesions. The medulla and cord reveal no degeneration. The diaphragm on the right reaches to the fourth interspace, on the left to the sixth rib. The thyreoid is enlarged. There is marked colloid degeneration with numerous small cysts filled with bloody fluid. The examination of the tonsils, pharynx, larynx, and trachea is negative. The right lung is adherent over the base. In the lower lobe there is marked hypostatic congestion with slight oedema. There is moderate anthracosis. There are numerous adhesions over left apex and left base; otherwise as on right side. No scars, infarcts, or abscesses found in either lung. The bronchial glands moderately pigmented; otherwise normal. The heart is large, the apex extending beyond the nipple line. In the pericardium there is a small amount of slightly turbid fluid. The pericardium is smooth. The right auricle contains a large post-mortem clot. The right ventricle is slightly hypertrophied and dilated. The heart muscle is soft, slightly cloudy, and tears easily. The tricuspid and pulmonary valves present no lesions. The tricuspid orifice is rather wide. In the left auricle is a large mixed clot, extending into the pulmonary veins. The left ventricle is empty, the walls hypertrophied and slightly cloudy. On the auricular aspect of the mitral flaps, at the line of contact, are two yellowish, |