viewer has had an opportunity of employing this hyperemic method of Bier in a case of tubercular knee. The results have been favorable as far as pain was concerned, but a slight ankylosis is present. Prostatectomy.-R. Harrison (Med. Record, May 13, 1905) says of perineal parostatectomy that he believes it of limited applicability and adapted principally to partial removals of the gland. Freyer's operation of supra-prostatectomy is considered the operation of choice in the majority of cases, some of its advantages being that it may be completed with a knife aided by the fingers in a very few minutes, and that the bladder and prostate are approached from their most accessible position where there is little danger of encountering hemorrhage or of permanently damaging the sphincter or retentive apparatus of the bladder. The drainage provided is free so that secondary strictures need not be feared, and any calculi present are sure to be detected and removed. Partial supraprostatectomies have not proved, on the whole, successful. In regard to the mortality attendant upon the two types of operation the author believes there is not much difference between them, and he puts it, including all causes of death, at about ten per cent. Gunshot Wounds of the Pancreas.-In Annals of Surgery, F. Gregory Connell reports and comments on a case of gunshot wound of the pancreas that resulted fatally. The case was in an adult 21 years old who was shot with a 32 caliber revolver. The bullet entered in the region of the seventh right costal cartilage. The symptoms were those of colicky pains in the region of the umbilicus, no distension of the abdomen, no marked rigidity or tenderness on palpation. Patient was restless and vomited a small quantity of red blood. The exploratory operation, one hour afterward, disclosed a through and through wound of the right lobe of the liver and a perforating wound of the stomach to the lesser curvature. No pancreatic lesion was discovered. Wounds in stomach sutured drainage not used. Patient died sixty hours after the operation. Autopsy disclosed the wounds in the stomach, sutured were not in a process of healing, and a portion of the stomach and pancreas were necrotic. Sero sanquinolent fluid was found free in the lesser peritoneal sac. No marked peritonitis. The author adds important physiological points regarding the digestive function of the pancreatic fluid. The intact peritoneum is not digested by this fluid, while the intact epidermis is affected. The result in this case the author ascribes to the fact that the injury to the pancreas was overlooked, and in consequence the gastric wound as well as the pancreatic wound were affected by the escape of pancreatic fluid. Since the mortality in these injuries is so great the treatment must be at fault. The author reports series of twenty cases from literature on the subject, successful cases are reported by Becker, which show a mortality of 65 per cent. The Slavosky, Barchard, Muir, Hahn, von Bergmann (2). In all but one case (Nissi) drainage was thoroughly established. The author speaks with little favor for the stitch method of repairing a pancreas, owing to the diffi culty of properly accomplishing same on account of the structure of this organ. Drainthe site of the injured pancreas is the best age posteriorly by rubber tube stitched to method of drainage. Gauze should be packed around tube and cover the entire bullet tract. Anterior drainage by tube and gauze should also be established. In this way the pancreatic fluid can find an exit externally. none of the above cases has a persistent fistula resulted. In MANY men with no taste for liquor buy drinks because only in a saloon can a public urinal be found in cities. THE PLAGUE IN SOUTH AMERICA.-Since the year 1903, when the bubonic plague first made its appearance on the west coast of South America, it has never entirely disappeared. During this year there seems to have been a recrudescence, particulary in the southern part. In March it began in Mollands, the port of Avequipa, Peru. In Lima there are one or more cases discovered daily. Though the type of the epidemic seems to be comparatively mlid and not extremely contagious, nevertheless it continues. Should it get a footing in the interior of the country, it would probably be more fatal than on the Coast, as the hygienic habits of the populationt here are worse than those of the Coast. The disease has made terrible ravages at Pisagua, Chile, and refugees from that town assert that for some time before their departure the deaths there had ranged from ten to thirty a day, and the authorities were then unable to enforce burials. Bodies were thrown into the streets and spread contagion. But little headway had been made in the fight on the disease, and it seemed as though the entire population of that Chilean port might be exterminated by the plague. Many persons had been shot down by the soldiers on guard while attempting to escape from the stricken city.-Med. Record. THE MEDICAL FORTNIGHTLY A Cosmopolitan Biweekly for the General Practitioner The Medical Fortnightly is devoted to the progress of the Practice and Science of Medicine and Surgery. Its aim is to present topics of interest and importance to physicians, and to this end, in addition to a well-selected corps of Department Editors, it has secured correspondents in the leading medical centers of Europe and America. Contributions of a scientific nature, and original in character, solicited. News of Societies, and of interesting medical topics, cordially invited. Advertising forms close on the first and fifteenth of each month. Time should be allowed to submit proof for correction Advertising rates on application. Remittances and business communications should be addressed to the Fortnightly Press Co. Subscription, $2.00 a year, in advance, including postage to any part of the United States, Mexico and Canada. Postage to foreign countries in the Universal Postal Union, including Newfoundland, $1.00 a year additional. Entered at the St. Joseph post-office as second-class matter. The Medical Fortnightly will not be discontinued at expiration of subscription, as many of our readers prefer not to have their files broken on account of failure to remit. Unless we receive a distinct request to discontinue, and payment for all arrearages, this magazine will not be discontinued. Subscriptions may begin at any time; volumes end with June and December. Contributors should understand that corrected typewritten copy is essential to clean proof and prompt publication, and is much more satisfactory than manuscript. Original articles should be as condensed as justice to the subject will allow. Editorial offices in St. Louis, Jacksonville, and St. Joseph, where specimen copies may be obtained, and subscriptions will be received. Contributions and books for review should be addressed to the editors, 319 and 320 Century Building, St. Louis, Mo. CLINICAL THERAPEUTICS A forum of original experience, to which scientific contributions are invited. Responsibility for views promulgated limited to author. THE "BINIODIZED OIL" OF PANAS IN SYPHILIS. ROBERT CROSBY, M. D. NEW YORK. Professors Panas and Fournier of Paris, were the first to suggest the hypodermic use of biniodide of mercury dissolved in oil, which is now becoming so popular under the name of cypridol, a name selected because it is often necessary to use some little consideration towards the patient, and cypridol does not suggest the specific nature of the disease to those about him. I have used it quite extensively and find it the most satisfactory of all the hypodermic mercurial preparations for more reasons than one, but chiefly because it does not cause nodules, pain or salivation, and, while, the oily solution of biniodide, as proposed first by Panas, was a weak solution, requiring rather large amounts to be injected, this one a 1 per cent solution of mercuric iodide and threrefore small amounts injected are sufficient. It appears also to be more prompt in its action than other preparations of mercury. I used it lately in a gumma of the eye, which had been neglected until the eye had opened through the breaking of the tumor. Iodide of potassium failed, even in large doses, to arrest the destructive processes, but eight minims of cypridol injected hypodermically caused the disintegration to stop immediately and it completely healed over within a week. Four injections were given to obtain this satisfactory result. At such critical times, where sight is endangered by delay, it is folly to delay these injections or rely on the slow process of absorption of mercury exhibited by the mouth, when such rapid results follow intra-muscular injection of cridol. Capridol in capsules can be given by the mouth in ordinary specific cases where no serious symptoms are present and is to be commended once the case is brought well under control with the injections. In my opinion, no internal murcurials should be used until such control has been obtained hypodermically. WANTED.-A DOCTOR to buy for $500 a $3,000 practice in Kansas. Good town of 1000. Competition easy. Good reasons for selling. Address PHYSICIAN, care Medical Fortnightly, St. Louis, Mo. In our own country concealment of age is regarded as a harmless fiction, and the practice is supposed to be rather prevalent among women who are more than twenty-five and under seventy-five. In Austria a more serious view is taken of this offence. By a recent decree of the courts of law a marriage was annulled on the husband showing that the bride had concealed the exact number of years that had passed over her head. She pretended to be fifteen years younger than she really was WHAT ANTITOXINE HAS DONE.-Ten years ago the antitoxin treatment of diphtheria was begun by the Department of Health of Chicago. During the previous ten years there had been 13,566 deaths from diphtheria and croup reported to the Bureau of Vital Statistics, a yearly average of 1,356, and a proportion of 13.53 deaths in every ten thousand of the population. During the ten years ended with 104 three were only 8,129 deaths reported, a yearly average of 812, and a proportion of less than 5 in every ten thousand of the population. These figures show a reduction of 5,437 in the actual number of deaths since the department began the antitoxin treatment. They show a relative reduction in proportion to increased population of nearly 64 per cent; that is to say, if the ravages of diphtheria had not been checked by the use of antitoxin during the last ten years there would have been 22,538 daths ininstead of 8,129-a saving of 14,049 lives. Vol. XXVII (Absorbed the Morgan County (Ill.) Medical Journal. January 1, 1903.) ST. LOUIS, JUNE 26, 1905. Papers for the original department must be contributed exclusively to this magazine, and should be in hand at least one month in advance. French and German articles will be translated free of charge, if accepted. A liberal number of extra copies will be furnished authors, and reprints may be obtained at cost, if request accompanies the proof. Engravings from photographs or pen drawings will be furnished when necessary to elucidate the text. Rejected manuscript will be returned if stamps are enclosed for this pur pose. COLLABORATORS. ALBERT ABRAMS, M. D., San Francisco. ARTHUR R. EDWARDS, M.D., Chicago, Ill Mr. REGINALD HARRISON, London, England. HOBART A. HARE, M. D., Philadelphia. CLINICAL LECTURE MYASTHENIA GRAVIS.* CHAS. K. MILLS, M. D. PHILADELPHIA, PA. Professor of Neurology in the University of Pennsylvania; Neurologist to the Philadelphia General Hospital. GENTLEMEN: The disease to which attention will be directed in the present lecture, while of comparative rarity, is sufficiently common to make it important that the general practitioner should be able to recognize it. In an experience in neurology extending over more than a quarter of a century, I have not seen more than half a dozen cases of this affection, or rather I should say that 1 have not recognized the existence of the disease in more than this number of instances. I am quite sure that in a few cases in my earlier experience I may have confused the disorder with others from which it is necessary to differentiate it. This lecture was in substance delivered to the fourth year medical class in the Hospital of the University of Pennsylvania, in March, 1904. Some additions to the lecture have been made in the form of comments, and of notes as to the condition of the patient about eleven months after the delivery of the lecture. No. 12 As early as 1879 the attention of the profession was directed by Erb to a group of cases which should be properly included under the head of myasthenia gravis. Hunt illustrates the force of the old proverb that "there is nothing new under the sun" by citing from Guthrie the fact that Willis in 1685, in "The London Practice of Physic,' described a disease which can hardly be other than the one under consideration. After the publication of the paper by Erb, isolated cases of myasthenia gravis were occasionally reported, some without and some with necropsies, and during the last ten or twelve years many additions to our clinical and pathological knowledge of this affection have been made. It is not my intention, however, in the present connection to review the literature of the disease, but rather to direct attention to an unusually interesting example of it, with some discussion of diagnosis, prognoIsis and treatment. To show that a study of the diagnosis of myasthenia gravis is even yet not unimportant, I might say that one of the most distinguished clinicians of this country made the diagnosis of cerebral syphilis in the case which will be shown to-day also; that I was recently asked by one of our best neurologists to see a patient dying with the evidences of paralysis in all the limbs, and in the muscles supplied by the bulbar nerves, in which the diagnosis of myasthenia gravis had been made, but in which necropsy and microscopic examination demonstrated the existence of inflammation and degeneration of the peripheral motor neuron system or should I spare myself in this connection, for in 1893 one of my clinical assistants under my own supervision reported an undoubted case of the bulbar form of this disease, a case in which, while the symptoms were fairly well detailed, the exact diagnosis was not made. The disease is indeed one likely to mislead. Many cases of myasthenia gravis have been reported under the name of asthenic bulbar paralysis, and this for the obvious reason that the symptoms are, in a considerable percentage of cases, solely or largely bulbar. Other cases, among which should be included the subject of this lecture, are properly designated + Hun, Henry. Albany Medical Annals, January, 1904. Hun gives a list of 124 references to the literature of this disease. The reader interested in a fuller study of the subject is referred to this paper. as asthenic bulbospinal paralysis. The symptoms which are in typical cases entirely motor indicate exhaustion either of the bulbar centers for the motor nerves, or of these and the spinal motor centers. The patient, a man 36 years old, was brought to me for examination by Dr. C. P. Large from one of the western counties of Pennsylvania. One year ago he was in perfect health, regularly attending to his business, that of jeweler. About June, 1903, he began to notice a little difficulty in using his legs, apparently as much in one as in the other. He observed, for instance, some slight evidences of weakness in gettting in and out of a carriage and in going up steps. With this exception he continued well until October, 1903, when, while in a procession, he found that he had considerable difficulty in standing and walking. He became fatigued and exhausted by an amount of exertion that would not have affected him in the slightest a short time previous. From this time he grew somewhat rapidly worse as regards weakness in his lower extremities. About a month later, in November, his eyelids began to droop, and within a week complete ptosis was present on the left side, while on the right it was partial. It was also noted that there was at times loss of power in some of the muscles of the left eye. He could for instance, the eyelid being raised for him, fix an object with the right eye, but when he did so the left would wander outward. With With an effort he could make the left eye fix with the other, but this only for a short time. This divergence of the left eye caused temporary double vision. He could from the first, as he can now, read with either eye closed. Both arms began to be affected with weakness in December. In February, 1904, he noticed for the first time some difficulty in masticating and some stiffness or want of power in the movements of the lips. Within twenty-four hours of the onset of these symptoms some difficulty in swallowing came on. From the first he has had no impairment or perversion of sensation or of the special senses. His bladder and bowels have continued to act normally. His mental powers have not in the least been affected. Let us now study the symptoms presented by the patient at this time. He has incomplete double ptosis. In looking he carries his head thrown somewhat backward, and also uses the frontalis muscle to overcome the drooping of the eyelids. Examining the movements of each eye separately it will be observed that they are greatly impaired, especially on the right. Dr. G. E. deSchweinitz, who has kindly examined the patient for me, reports as follows: Right eye-slight ptosis and palsy of all the external ocular muscles, rotations be. ing limited in some directions to less than ten degrees. Left eye-palsy of internal and superior rectus: partial ptosis. The ocular symptoms seem to be typical of involvement of the nuclei of the ocular external muscles, almost complete on the right and incomplete on the left. The ciliary muscles are unaf fected. The discs are somewhat pallid and the retinal veins full, but there is no neuritis nor atrophy, and no retinal or choroidal lesions. The fields are normal. The irides respond to light, accommodation and convergence, as I demonstrate, an assistant helping the patient's voluntary efforts to elevate his lids. The movements of the face are all impaired, or at least soon tire. Oral movements are weak. He opens and closes his jaws properly, but a repetition of the effort soon fatigues him. He has difficulty in swallowing ap preciable to himself but not very evident to others. All the movements of the tongue can be performed, and the patient is not aware of any fatigue after talking. All the movements of both the upper and lower extremities are present, but all are impaired. (The patient was tested as to his grip and also as to various movements as of flexion, abduction, elevation, etc., in both upper and lower limbs, both with and without resist. ance, the result showing a general diminution of power and the rapid coming on of fatigue, but no real paralysis.) Knee jerks and quadriceps jerks were diminished on both sides, but more markedly on the left. No ankle clonus is present and no Babinski response. The Achilles jerk is absent. In the upper extremities the tendon and muscle responses are diminished, the von Bechterew reflex is absent. On a number of occasions since the patient's admission to the hospital, tests have been made both by Dr. Spiller and myself, which show the tendency to speedy exhaustion of muscles as the result of voluntary effort. When the patient was made to look up continuously, his upper eyelids gradually drooped until the left eyelids touched and the right were separated by a space of about one-eighth of an inch. one-eighth of an inch. This drooping oc curred within two or three minutes. After resting four or five minutes he was again able to separate his eyelids, but not quite as much as at first. His eyes are sensitive to a very bright light. After reading the news paper for about five minutes, his arms would drop so that he could not hold the paper. On first getting out of bed he is able to stand with his feet together and with his eyes closed without swaying and is able to walk across the room, his gait being fairly good; but after he has walked the length of the room four or five times, his gait becomes irregular and he has difficulty in lifting his feet from the floor. His steps gradually become very short and after walking six or seven times across the room, he is unable to go any further and complains of fatigue in the small of his back. Several tests were made in this case to determine the presence of the so-called myasthenic electrical reaction of muscle and nerve, a clinical phenomenon which was first demonstrated by Jolly. This, however, was not clearly shown, although some diminution in response was present in one or two groups of muscles after prolonged application. Dr. C. S. Potts, who made the electrical tests, reported that he could find no evidence of the existence of the myasthenio reaction in any muscle. He caused from thirty to fifty contractions of each muscle tested, without any diminution in the force of the contraction being manifest. The calf muscles, biceps and extensors of the wrist were maintained in tetanic contraction for two minutes without any evidence of exhaustion. There seemed to be some slight diminution, most marked in the peroneal groups, of faradic contractility in both legs. All of the muscles of the arms, legs, face and the pectorals were tested. While the myasthenic reaction is sometimes present, this is not always the case. Dr. Mosher, who examined the case of Hun, found it well exhibited. Harry Campbell and Edwin Bramwell* in a critical digest of myasthenia gravis say that the myasthenic reaction is not present in all cases. In some it only occurs as a passing symptom, while in others it is never obtained. The patient was taken home after about three weeks' stay in the hospital, no manifest improvement having taken place at this time. As interesting in connection with the question of prognosis, I append a letter received from Dr. Large. This was written about ten months after patient left the hospital. "Received your letter concerning Mr.- and am glad to report to you that he is getting along very nicely. He walks everywhere, up and down stairs, and around town without the use of a cane or other assistance and during the day follows his usual vocation of jeweler and watchmaker. The ptosis has practically disappeared. He eats well (two meals a day) *Brain, 1900. and sleeps well. Last April after his return from Philadelphia, he seemed to decline rapidly, and it looked as though he could not live. He could retain no medicine on his stomach. After what seemed to be a crisis, he began to get strength and improved slowly. I might state that when he was the worst he was practically paralyzed from head to foot, tongue and throat included. Upon every attempt to swallow, solids would lodge in the throat and fluids regurgitate through the nose. One could scarcely understand what he said. He was the illest man I ever saw that did not die. His medicine became so irritating that it had to be discontinued. He vomited almost continuously mucus and pus of a very offensive odor. The only thing he could keep down was a little elixir lactopep tin. This condition lasted for a week or ten days and then gradually improvement began. I got him up into his wheel chair and out into the fresh air as soon as he was able to be around. He was rubbed all over with oil and the faradio current was applied to his spine. Now he has resumed his natural weight and seems like himself again. His mind is as clear as ever and he conducts all his business affairs himself. Of course he is not strong as before his illness, but considering his condition now and then, it seems nothing short of miraculous. His recovery seems probable from his present rate of improvement. A careful survey of the history of this case and the symptoms presented at different stages show clearly that it is one of myasthenia gravis. The bulbar symptoms most commonly present in the affection were exhibited by him. The disease showed a tendency to become worse in paroxysms with longer and shorter intervals of relief and great improvement. Some of the attacks were of so serious a character as to make death seem imminent, and yet after the lapse of nearly a year he so far recovered his muscular power as to be able to transact business in his usual manner, and to enjoy life in large degree. Hun's summary of the chief diagnostic features of myasthenia gravis was confirmed in the present case with the exception that the myasthenic reaction could not be clearly determined. "The important positive symptoms in establishing a diagnosis," says Hun, are (1) a chronic paresis affecting muscles supplied by many motor nerves, both spinal and cranial (ocular and bulbar); (2) rapid tiring; (3) variation in the intensity of the symptoms, and (4) the electrical myasthenic reaction. Of almost equal diagnostic importance are the negative symptoms: the absence (1) of fibrillation; (2) of muscular at |