groups: 1. The theory of digestive disturb. ance. 2. The theory of external irritation. 3. A group composed of all the remaining theories, dentition, vaccination, diathesis, etc. He rejects the third group as being overwhelmingly routed by his statistics, and confines his attention to a consideration of the first and second. As to the first, he says, that "the evidence is insufficient to support the theory of digestive disturbance, or malassimilation, as the cause of eczema, and that, on the contrary, there is considerable weight of evidence, as regards the digestive system, which is strongly opposed to such a theory. His reasons for this conclusion are as follows: (a) In most of the cases there is no history of any other symptom of digestive dis. turbance having preceded, or accompanied, the first appearance of the eruption. (b) Most of the cases have shown no symptom of digestive disturbance during the whole of the period during which the eruption lasted. (c) Neither rickets nor malnutrition was present in any considerable number of cases. (d) Most of the cases were breast-fed at the time of the first appearance of the eruption. (e) In most cases, the same mother had suckled previous children, under similar conditions, none of whom suffered from eczema. (f) There is no evidence of excessively frequent child-bearing, over suckling, or illness of the mothers. (g) Only a very small proportion of the whole number of cases occurred during the three summer months, the period during which infantile gastrointestinal disturbances are by far the most common. "Also," he adds, "If digestive disturbance is the cause, why does the eczema continue long after all the digestive disturbance has been regulated or removed, and why does it not occur oftener at the stage of weaning, when far more irregularities of diet occur than during the first three months of life, and lastly, how does this theory explain the fact that severe generalized recurrences occur after the infant rubs himself, even though there be no change in the diet at the time?" And now, to come to the second theory, that of external irritation. He regards the claim that the presence of a constant pathogenic organism is essential to the development of eczema, as not yet proven, but believes in the theory of external irritation based on the following considerations: 1. In almost every case the eruption commences on some part of the head or face. In the infant, during the first few weeks of life, this is practically the only exposed part. 2. The secondary distal eruptons on other parts are usually of much less severity, and tend to disappear directly the original sites recover, unless they (the former) are irritated. The comparatively constant age at which the

3.

eruption first appears, about the time when the infant is first released from the more extreme protection which it has received during the first few weeks of life. 4. The greatly increased percentage of cases which begin in the colder months of the year, varying markedly with the temperature changes in each quarter, and particularly showing an increase in number where there is a sudden decrease of temperature. This eczema, due to external irritation, he calls "traumatic," and regards it of the same type as the "traumatic, or occupation, eczemas" of adult life, the traumatism in infancy being inseparable from that time of life. Traumatism or "occupation of infancy" entails at birth, for the skin, sudden change from being surrounded by a dilute saline solution at a constant temperature of about 100 deg. F. to a surrounding that is gaseous, of a considerably lower temperature, and one whose temperature varies considerably. The infant's skin, also for the first time, makes acquaintance with soap, micro-organisms which infest the hands and faces of all who handle it, and the sweat from its mother's skin. Also, the infant cannot localize, nor ask for the removal of any of these irritants which may worry it, nor can he tell when he is not thoroughly dried after a bath, and this imperfect drying of the skin is a well-known cause of irritation even in adults. As to the secondary, distal outbreaks, all the reflexes of the infant, cutaneous and otherwise, are much more highly developed and sensitive than in the adult. So, of the above mentioned classes of irritants, which almost never occur alone, he classes cold first, coupled with imperfect drying and irritating soaps, the micro-organisms, though playing an important part, acting only secondarily, except in few cases where the trouble begins as a seborrhoic dermatitis from diet infection from a seborrhoic mother or nurse. He concludes with the suggestion that "eczema, whether it occurs in infants or adults, is a form of reaction, or response, of the neuro-cutaneous apparatus to external irritation; that it does not exist in most people; that in many it is called forth only under exceptional forms of irritants, or at times of ex. ceptional nervous irritabiilty; and that, in a few, it is so readily roused, even by the ordinary external stimuli of daily life, that they are constantly affected.

CONSISTENCY.-A vinegar manufacturer of Boston who recently lectured in his native town on "The Dangers of Adulterated Foods" was fined in a municipal court for adulterating his product.

OTOLOGY.

ALBERT F. KOETTER, M. D.

Stricture of the Eustachian Tube. Wendell Phillips (Post-Graduate) reports case of a patient, age 29, who since her fourth year, following an attack of scarlet fever, has been deaf.

On

Being very bright she retained her speech. No treatment was given for the ear trouble in all these years. Tuning fork test left better than right. Watch heard about four inches on both ears. Acoumeter heard four feet on left, six feet on right. On examining found thickening and sclerosis of left membrane, retraction very marked. Catheterization did not improve hearing. third day introduced a bone bougie through catheter, encountered an obstruction which was finally overcome and bougie passed into the tympanic cavity. On inflation air went through with ease. Immediately on withdrawing catheter patient heard sounds she had never heard before. On testing she heard watch tick at 30 inches and the acoumeter twenty feet. Patient heard hissing of boiling water and ticking of clock. She was told that hearing would go back, but such has not been the case. Author advocates the intelligent use of the bougie, but warns against use of electric bougie except in hands of expert. The patient above mentioned will do very well with an occasional use of the bougie.

Artificial Drum-heads and Other Aids, to Hearing.-Alex. Randall (New England Medical Monthly) gives some plain facts as to devices used to improve hearing, as advertised in the daily press, etc. Trumpets are conspicuous and annoying, and therefore deaf people take readily to any device which may improve the hearing and hide their defect. Artificial drum-heads often prove very irritating and make conditions worse if allowed to remain in ear any length of time. When suppuration is present these drum-heads may interfere with cleansing and proper drainage. Electrical devices constructed on the principle of a microphone are supposed to work wonders, they do help where there is a defect for low tones. These appliances exhaust the nerve force and make the ear impervious to tinnitis, this certainly should be a warning for any remnant of hearing that may be present. The physician should be aroused to the damage these devices may do to the individual who uses them.

Mastoiditis in Typhoid.-Fred. Baker (California State Med. Jour.) Boy of 19 in May, 1900, suffered from an acute middle ear suppuration which disappeared under treatment.

Facial Paralysis After Injury to the Ear. -(Zimmermann, Wisconsin Med. Jour.)— Man of 50 fell from the platform of an electric car striking the street with the right side of the head, loss of sensorium, hemorrhage from the right ear, since then suffers from vertigo and deafness. On examination eight days later right canal filled with clotted blood and epithelium. Rupture of lower half of tympanic membrane. tympanic membrane. Loud voice heard one foot from ear. Rinné negative. The next profuse bloody discharge and the following day paralysis of right facial nerve, more pronounced in the lower than in the upper branches. Ophthalmoscopic examination revealed no changes. After three days perfor ation closed, paralysis complete. Catheterization improves hearing considerably. After six months paralysis had entirely disappeared I was under treatment, hearing normal. called in to see a case about three years ago similar to one reported above. A man of 55 was thrown from a lumber wagon falling on his left shoulder and head. He suffered a fracture of the clavicle, also developed a paralysis of the left facial nerve. On examina

tion external canal on left side was found full of blood and epithelium, which when removed showed a perforation in the lower anterior quadrant. Paralysis disappeared after two months, hearing normal. This patient was a hard drinker, and had complained of dizziness for three months previous to the injury; in one of these attacks, he fell from the

wagon.

He

The Physiological Tinnitus Aurium.Zwoordemaker-(Mederl. Tydsche.foor Geneeskunde) describes the newly arranged acoustic room of the physiological laboratory, in which there is no resonance and through whose walls no sound can penetrate. further mentions the psychic impression of rest which one has in this room. A sea shell does not hum or buzz in the room. normal ear buzzes. In most persons this buzzing is of two kinds: 1. Soft buzzing as of the wind blowing through the tree tops. 2. Soft noise as of the chirping of the cricket. Author explains these noises and also the pathological noises of vascular and

Every

nervous origin. He finds a practical value in these studies of the physiological tinnitus in a noiseless room, in so far as in many pathological cases the same condition exists, viz., acoustio isolation. In fact the author found many analogous points between physiological and pathological tinnitus.

PATHOLOGY AND BACTERIOLOGY.

R. B. H. GRADWOHL, M. D.

The

Rupture of the Aorta and Arterio-Sclerosis in Children.-Rudolf Openheimer (Virchow's Archiv, Band 181, Heft 2, August, 1905) states the differences of opinion in the past as to the etiology of arterio-sclerosis. Virchow for instance always considered that it began in the intima of the vessel, while Tboma and Birsch-Hirschfeld always contended that the media was the part first affected. Recklinghausen and Helmstedter noticed changes in the media in cases of aortic aneurism. difficulty in eventually solving this problem lies in the fact that arterio-sclerosis is essentially a chronic process, extending over a considerable period of time. Experimental production of arterio-sclerosis by the injection of adrenalin in the writer's opinion could hardly explain all the cases which are due to causes other than adrenalin injections. Op. penheimer was fortunate in being able to observe two cases of arterio-sclerosis in children between the ages of 9 and 10 years, one of which was followed by spontaneous rupture of the aorta. Case 1.-Female child of nine years, with healthy parents; no history of trauma; previous history good. On January 15, 1905, the child was suddenly seized with palpitation of the heart, great weakness, followed on the following morning with great pain in the region of the heart. There was considerable dyspnea. The child then improved and felt normal for a few days until at noon un January 18, 1905, she suddenly collapsed and died. Autopsy disclosed blood clots in the pericardial sac which were due to the rupture of the aorta just above the margins of the aortic valves. The aorta at that place was dilated over an area approximating one-half by two cm., with the the rupture in the center. The rupture had involved principally the intima and the media. The edges of the perforation were thickened and rolled inwards. While the intima showed a gap of one-half cm. wide at the site of perforation, the adventitia showed only very minute opening. The intima in the neighborhood of the rupture did not show any signs of arteriosclerosis. Just above the aortic valves were two slightly thickened areas. There were

no signs of arterio-sclerosis in the other vessels of the body and no lesions in any of the viscera. There were no evidences of lues. This was then a case of spontaneous rupture of the aorta, which is a very rare Occurrence in childhood. Four different

parts of the aorta were examined microscopically: (1) at the site of perforation; (2) at the sclerotic site; (3) at a point where the vessel was infiltrated with biood, and (4) places where there were no visible alterations. As a total result of these different microscopic exminations, the writer came to the conclusion that the media was the part first and principally affected and that the perforation was a result of the tear in the media. In the parts appearing normal to the naked eye, the media showed tears in the elastic fibers; the sections near the site of perforation also showed this same tear.

Case 2. This was a boy of 10 years, with resected left hand on account of a tubercu lous process. Later on symptoms of acute nephritis set in which resulted fatally. Autopsy showed acute nephritis, with left fibrinous pleutritis. Heart was size of fist, left ventricle contracted, valves hard. The aorta showed on the inner surface two thickened places about size of peas. They lay about 3 om., above the approximating edges of the valves. No other signs of arterio-sclerosis in the aorta. No signs of lues were found. The placques and apparently normal parts of the aorta were examined microscopically. The arterio-sclerotic spots showed thickening of the vasa vasorum. The walls of these vasa vasorum were thick and showed hyaline degeneration. New vasa vasorum were seen in the media aswell as in the adventitia. The parts appearing normal to the naked eye when submitted to the microscope showed that the adventitia was affected. The intima was normal, as was the media, but the adventitia showed a cellular infiltration into the lymph spaces. The adventitia was widened, the vessel walis of the vasa vasorum markedly thickened. Here and there the walls of the vasa vasorum showed hyaline degeneration. In the neighborhood of the vasa nutritia were groups of round cells. It can thus be seen that the writer had two cases of arterio-sclerosis in young subjects, differing in that one case showed the process beginning in the media while in the other it began in the adventitia. The difference in the disease processes in these two cases speaks from a difference in their etiological factors. In the first case the etiology appeared to be a weakness in the blood vessel wall coupled with a great amount of blood pressure upon that congenitally weak part. In the second case, there was a toxic agency in the causation of the disease. Both cases

while differing as to cause resulted in morphologically the same process, i.e., arteriosclerosis.

A

more

Report of the Medical Commission for the Investigation of Acute Respiratory Diseases of the Department of Health of the City of New York.- Part 1.-Studies on the Pneumococcus (reprinted from the Journal of Experimental Medicine, 1905, Vol. VII, No 5). In August, 1904, the Board of Health of the City of New York appointed a medical commission for the purpose of conducting an investigation as to the causes of the great prev. alence of the acute respiratory diseases in that city, with the hope that some means could be devised for reducing the excessive morbidity and mortality from this cause. consideration of the etiology of the acute respiratory diseases brings out even strongly the sanitary importance of the problem. The exciting cause is a micro-organism which requires certain conditions of the body for its growth. The conclusion seems justifiable that these diseases are especially communicable and they should be preventable. The difficulties in prevention are largely from the wide distribution of the organisms. the problem under consideration is not simply one which concerns New York, but one which almost equally concerns all the large cities of the United States, it was felt to be important that the commission should have a representative character. The commission was constituted as follows: Dr. Edward G. Janeway, New York, president; Dr. Wm. Osler, Baltimore, vice-president; Dr. T. Mitchell Prudend, New York, secretary; Dr. Theobald Smith, Boston; Dr. Frank Billings, Chicago; Dr. John H. Musser, Philadelphia; Dr. L. Emmett Holt, New York; Dr. Francis P. Kinnicutt, New York (Extract of Preface).

As

Introductory Note.-The medical commission began its work in October, 1904.

was decided to concentrate attention at first upon lobar pneumonia in both its bacteriological and clinical aspects. The following studied were pursued:

1. A study of the occurrence and virulence of pneumococcus and organisms relating to or resembling it, in the human mouth and in disease.

2. The evidence of variations in virulence of the pneumococcus.

3. The occurrence of the pneumococcus in children's hospitals, homes and asylums, with study of the bacteria of mouths before and after outbreaks of pneumonia.

4. The vitality of the pneumococcus under various conditions.

5. A study of mouth disinfection.

It was the sense of the commission that one of the earliest phases of the work would be the determination, for the identification of species, of the characters of the pneumococcus, is investigation to include a study of the pneumococcus from true lobar pneumonia and from normal mouths and throats, and also a study of streptococci to separate them from pneumococci. To accomplish this, a corps of bacteriologists was selected, composed of Dr. W. T. Longscope of Philadelphia, C. W. Duval and Paul Lewis of Boston, Dr. Wm. H. Park and his associates in the department of health of New York, Dr. Lee Brueger of New York, Prof. F. C. Wood of New York, and Dr. Chas. Norris of New York. The cooperation of Prof. Hiss, of the College of Physicians and Surgeons of New York, was secured in the organization and direction of the work of the 'central laboratory at the College of Physicians and Surgeons.

The first paper published in order was that by Dr. Wm. H. Park, A. W. Williams, A. Oppenheimer, C. Bolduan, J. L. Berry, M. A. Assersen, M. Lowden and I. Van Giesen, on "A Comparison between the Pneumococci found in the Throat Secretions of Healthy Persons Living in both City and Country and those obtained from Pneumonic Exudates and Diseased Mucous Membranes." They concluded from their work that:

1. Typical pneumococci were present during the winter months in the throat secretions of a large percentage of healthy individuals in city and country.

2. A higher percentage of atypical strains of pneumococci have been obtained from healthy persons than from those suffering with pneumonia. Many of the atypical strains seem to have been related to streptococci.

3. The so-called streptococcus mucosus Schottmueller, which has hitherto been classed with the distinct streptococci, is placed as a definite variety among the pneumococci, and it is recommended that its name be changed to streptococcus lanceolatus, var. mucosus.

4. A lower percentage of strains of pneumococci virulent for rabbits in the doses used has been obtained from normal cases by rabbit inoculations of mass cultures than from cases of pneumonia by the same method.

5. Since the virulence of pneumococci may be rapidly increased for a susceptible species of experimental animal by successive inoculation, and since pneumococci obtained from most pneumonias are more virulent for experimental animals than are those obtained from healthy persons, therefore the virulence of pneumococci from cases of human infection is probably increased for human beings;

7. Coincident with this production of this protective power, a slight specific increase of the sheep serum in phagocytic power in vitro has been observed with some strains of pneumococci, all strains of streptococcus lanceolatus, var.mucosus, acting similarly with the serum produced by the inoculation of one strain; the strains of some other varieties, however, have shown no definite relationship between the phagocytic power and the protective power of the serum.

The paper by Norris and Pappenheimer concludes that organismis of pneumococcus or streptococcus group are present in the lungs of practically all cases, whether normal or showing a variety of lesions; strictly speaking they were found in forty out cf forty-two cases, or in 95 of their series. They found that test organisms small portions of the bacillus prodigiosus, introduced into the human mouth after death, were conveyed to and recovered from the lungs by culture in a little over half of the cases in which the experiment was tried. The test organisms were conveyed to the lungs, they believe by the fluid which collects in mouths of persons after death, and which in many cases collects just before death. The numerous manipulations of the body in its removal from the wards to the morgue greatly facilitate the entrance of any fluid from the pharynx and buccal cavity into the lungs.

It follows therefore from these experiments that the cultural findings after death are no guide to the bacterial contents of the lungs during life, and that any deductions made from such findings are unreliable. Granting the explanation given, there is every reason to believe that any of the organisms seen in the mouth and pharynx or even stomach contents may enter the lungs, and if the conditions are suitable, increase in number, during the time between the actual moment of death and the examination of the lungs. These writers were unable to determine anything as to the presence of pneumococci in the lungs

during life, or as to the channels by which they gain access hereto.

Buerger's paper contains the conclusion that normal individuals in whose mouths it is impossible often to find the pneumococcus, may acquire the organism by association. with pneumonia or "positive normal" cases. The handkerchief and dishes of pneumonia and "positive normal" cases are to be regarded as some of the means of transference of the organism from person to person. lips of drinking-cups and the sputum or saliva in sputum cups were found to contain living and virulent pneumococci.

The

A most interesting paper of the collection was by Francis Carter Wood on "The Viability of the Pneumococcus after Drying: a Study of one of the Factors in Pneumonic Infection." He made a number of experiments with drying out of sputum and also by He summarized as folspraying sputum.

lows:

I. In moist sputum kept in the dark at room temperature the average life of the pneumococcus is eleven days, though considerable variations may be noted in different speciat zero Centigrade, the average life of the ormens of sputum. In the same sputum kept ganism is thiry-five days. In sputum kept at room temperature and in strong light, the average life of the pneumococcus is five days.

II. In dried sputum (a) in the dark the (b) in diffuse light thirty days, and (c) in pneumococcus lives about thiry-five days; sunlight, less than four hours.

III. In powdered sputum even when kept in the dark the pneumococcus dies in from one to four hours. When exposed to sunlight, the organism dies in less than an hour.

IV. No important differences were noted in glass, tin or wood. the life of the pneumococcus when dried on On cloth the life was usually slightly longer that on non-absorbing

surfaces.

V. Sprayed sputum particles remain in suspension for twenty-four hours, but all

masses of a size sufficient to contain bacteria settle at a rate of about 40 cm. per hour.

VI. When sputum containing pneumococci is sprayed, the organism rarely lives beyond an hour, and often dies in less time. The substance upon which the sputum is sprayed makes but little difference in this result. On cloth a slight prolongation is usually noted, due perhaps to the slow drying.

VI. The mucus of the sputum exerts a destructive action upon the pneumococcus

VII. Exposure of the bacterial spray to sunlight which in suspension results in the destruction of the pneumococcus in less than half hour.

IX. It can therefore be estimated that the