to give their parents the proper education in child care, to the end that those children, rich and poor, shall have that equality of good health which is their inalienable right, is a big question. I believe that there is much that is good in the present agencies working for child welfare; we should adopt it as our own. I believe that there is much that is unwisely done by these same agencies; we should offer out of our wisdom better methods. And, lastly, we should by constant application of our knowledge of prophylaxis to our private practice, do our share individually to make preventive medicine a real force. It is not that we have lacked knowledge, but that we have lacked initiative. I have no patience with those who hold that our present system is sufficient. The fact is that it has failed miserably. It lacks aggressiveness. Diagnosis and treatment have been its scope and often the fee its highest ideal. I do not believe, on the other hand, that private practice is doomed, nor do I believe that we should work for an inadequate fee. An underpaid medical profession will never be an asset in the social order.

We must instruct our patients and their families beyond the present emergency. Any obstetrician who delivers a baby without impressing upon the mother the importance of breast feeding has cheated the patient and discredited the profession. Any physician who attends a case of infantile paralysis thru the acute stage without giving explicit advice as to the care during convalescence is remiss in his duty. We must learn to look beyond the disease and see the patient. If you remove the tonsils of a delicate child and consider your work successful when the throat is healed,

you are false to the ideals of your profession. Your duty requires that you attempt at least to see that that child gets the proper diet, hygienic care and medical attention for his constitutional condition, if all these be necessary. If the parents can afford no more than your services, it is up to you to see that further care is provided by proper organizations. As a rule, we prescribe tonics too frequently, specific advice too seldom.

I believe that it will be up to you to provide your services as a specialist in some sort of an organization or agreement by which a patient needing specialist's services beyond his means, may secure them at a price reasonable to him, and retain his self-respect, and this despite any preconceived notion you may hold upon the subject of cut-prices. I believe that we should associate ourselves with every organization dispensing medical relief to the less fortunate. Not only will this enable us to do our own charity work on an organized basis, but it will be a stimulus to better work, and only in this way do we acquire the moral right to take active part in planning the program of such institutions.

That remarkable woman, Florence Nightingale, once said with reference to criticisms of the hospital system of her day something which applies well to our questions today: "I have always believed and I believe it now, and more every day I live, that what is wrong with the hospitals is to be patiently, laboriously and, above all, quietly mended by efforts made from within them, and not by accusations, investigations and noise from without."

607 Beach St.

The Interstitial Gland.-Morley discusses this subject (New York Med. Jour., March 2, 1921) and says that the term interstitial gland was given to a special group of cells found in the ovary of animals by a Frenchman, M. Bouin, about 1900. Later this name was applied to similar cells or groups of cells in testes by P. Bouin and P. Ancel, in 1903. Since that time much work, both research and clinical, has been done, and the literature is rich with monographs, memoirs and case reports of the interstitial gland. As to the origin of these cells, whether in groups and forming an interstitial gland or scattered about singly in the ovarian connective tissue, there seems to be much difference of opinion. Falta has made the statement that an interstitial gland, in women, is a cell complex that develops from the theca interna of atretic follicles. In explanation, an atretic follicle is a Graafian follicle that has not reached full development, that never has contained an ovum, and hence does not ripen and discharge its ovum. But aside from this group of cells found in the female ovary, there are numerous cells of like character scattered thruout the ovarian tissue. In the testes the interstitial cells are found in the interstitial tissue between its seminiferous tubules, and are arranged in irregular groups. These latter are often referred to as Leydig's cells. There is no doubt that this scattered and irregular arrangement of the cells has led to much inaccuracy in their study, and that at certain seasons, such as rutting and hibernation, many errors have resulted in observing whether these cells were atrophic, hypertrophic, or hyperplastic. To repeat, the interstitial cells, a group of which is called an interstitial gland, arise from the theca interna of an atretic follicle, at least the majority of observers agree; some few maintain that they are of stromal origin. Where the interstitial cells of the testes originate, has not been deter

mined. The point to remember is, however, that there are such things as interstitial cells; that a group of these cells, in the ovary especially, is called an interstitial gland, and that while there seems to be some difference of opinion as to their origin, nevertheless they do exist.

Concerning the function of these interstitial cells and hence of the interstitial gland, the consensus of opinion seems to be that they are part of the internal secretory mechanism of the ovary, and the chief, if not the only, source of the internal secretion of the testes. It is supposed, and to some extent is proved by clinical observation, that in the female up to the time of puberty and after the menopause the entire source of the internal secretion of the ovary is the interstitial gland. Between puberty and the menopause the corpus luteum, acting in conjunction with or independently of the interstitial cells, produces the internal secretion of the ovary.

The Suprarenal Glands in Deficiency Diseases.-The widespread effects of the absence of vitamines in the diet on certain organs apparently remote from their influence is perhaps only just becoming recognized says an editorial writer in the Lancet (Feb. 19, 1921). R. McCarrison, in his observations in an article in "Proceedings of the Royal Society," 1920, vol. xci, on the genesis of edema in beriberi, states that in pigeons suffering from experimental beriberi the edema is always associated with considerable increase in the size of the suprarenal bodies and that four-fifths of the animals with enlarged suprarenals show some form of edema. The adrenalin content was increased proportionately to the weight of the organs. The pigeons had been fed on polished rice heated in an autoclave, until they showed signs of polyneu

ritis. In 10 out of 22 pigeons edema occurred. The increase in size of the suprarenals is a true hypertrophy at least of the medulla, and if the increase of the adrenalin content can really be brought into causal relation with the edema, it is possible that this factor may be found to play some part in the production of edema generally. While the size of the suprarenals appears to have relation to the absence of the antineuritic factor, it would appear that the suprarenals are also affected by diets deficient in the antiscorbutic vitamine, as shown by the experiments of Victor K. La Mer and H. L. Campbell, of Columbia University. These observers fed young guinea pigs, weighing 250-300 g., on a diet deficient in the antiscorbutic vitamine, and found an increase of weight of the adrenal glands amounting to approximately 100 per cent. when computed on the basis of body weight minus alimentary canal. Control animals which have been subjected to starvation do not show an increase of adrenal weight, which, in those fed on scorbutis diet, is directly proportional to the time during which their food has been deficient. It is most pronounced in those animals. whose life has been prolonged by the partial protection afforded by small but insufficient quantities of tomato juice. La Mer and Campbell interpret the increased weight as indicating a compensatory response to the decreased adrenalin production known to exist in the scorbutic animal, a point which has interest in connection with the extensive intramuscular and intestinal hemorrhages found in scurvy. The heart and kidneys are increased on the scorbutic diet, while there is no evidence that the liver is affected by a lack of watersoluble C alone.

ciple of the gland, an extract of the whole organ is usually given. If animals are castrated and glandular extracts injected, the effects which should result from the unsexing do not supervene. Extracts have been prepared from human ectopic testicles which consist wholly of interstitial tissue but the results have been disappointing. The good effects claimed for the extract of Poehl are not obtained by those who have tested it. Ever since the first trial of testicular therapy by Brown-Séquard cures of impotence have been claimed, but these were probably cases of psychical impotence only. Results obtained in children, especially about the time of prepuberty, in cases of anomalies of growth and development, appear to show that the remedy may have some power in the undeveloped male. Souques, in fact, gives it with other extracts in infantilism. An empirical or chance effect in relieving constipation has been claimed by several who have given the gland to neurasthenics, but apparently only when injected hypodermically. The usual dose has been five grains of the dried extract two or three times daily. The author does not mention either massive doses or the use of the remedy over prolonged intervals of time, but doubtless the treatment would not have been abandoned without a complete trial, including subcutaneous injection.

Suprarenals and Respiration.-Sajous (New York Medical Journal, Feb. 14, 1920) describes the function of the suprarenal secretion in regard to respiration. There is in the blood some substance which has the power of taking up oxygen from the pulmonary air cells. Henrique, in 1897, demonstrated the presence in the alveolar walls of a substance capable of absorbing the atmospheric oxygen. This substance, Sajous considers, is adrenalin. The marked affinity of adrenalized plasma for oxygen causes it to absorb this gas from the alveolar air. This affinity of adrenalin for oxygen can be shown experimentally, for when blood from the adrenal veins is diluted with saline solution, it quickly assumes a bright red arterial hue, while blood from other organs treated similarly shows no change.

The presence of adrenal ferment (adrenoxidase) can also be demonstrated in all nerve fibres and nerve cells, and Sajous considers all nerve cells are also the seat of

a' respiratory process, and of active metabolism. Respiration, the very life of the tissue cell, is influenced by the adrenal hormone, and the oxygen intake of the cell is under the control of the adrenals. The author considers that death from pneumonia is due to failure of the adrenals-weak adrenals mean weak metabolism and weak defences. The failure of the adrenals in pneumonia is very marked in the aged, for the adrenal vessels have degenerated and the organ itself is correspondingly deficient. In epidemic pneumonia the toxin, or filtrable virus of the disease, causes, in the opinion of the author, a paresis of the adrenal function, which inhibits general oxidation and metabolism, thus causing the familiar asthenia and low blood pressure. Hypoplasia of adrenals has been frequently found at autopsy after influenzal pneumonia.

The Modern View of Thyroid Disorder.-The thyroid glands, according to a writer in the Therapeutic Digest, produce and discharge into the blood and lymph a complex secretion which contains, in case of normal metabolism, the exact amount of active principle or hormone required to maintain a normal condition. This substance influences certain tissues directly and affects many functions of various organs. This action is performed thru humoral channels and is accredited to the hormone contents. These hormones are essential to life, a fact which explains the danger involved in extirpation of thyroid glands. Imperfect development, or disease of the thyroid caused by disturbed metabolism, malnutrition, unfavorable climate, or altitude, impure water, etc., are a great menace to health and life. Cretinism and myxedema are both associated with a deficiency of the thyroid secretions. A similar condition is produced by the surgical removal of the thyroid gland.

Endocrinology in Parmacodynamics.Bate (Medical Review of Reviews, June, 1920), points out that the physiologic action of every living cell is conceded to be under the control of internal secretions. Medicines administered by the mouth, stomach, rectum, respiratory tract, skin and veins, by arterial transfusion or by rays, all

produce their effect by endocrine activity, which is due to the medicine having been brought to its place of assimilation by ameboid leucocytes or body corpuscles. These body corpuscles wander everywhere thru the spaces of connective tissue; hence the dire consequences of connective tissue changes to an organ. If a drug is administered by the skin, mucous or serous membrane, there is probably a selective leucocyte affinity that determines the carrier. If direct administration within the tissues is practiced, probably an enforced leucocyte activity results. It is probable that prolonged hypodermic medication may thus result in harm. Drugs introduced into a body without ductless glands would probably produce no action of any kind. Drugs introduced into the body with inactive ductless glands, without the help of artificial endocrine substances, would probably have. little or no effect. Drugs introduced into a system with active endocrine organs produce their physiologic action by stimulating or inhibiting those hormones or chalones that control the physiologic or inhibiting action of cellular life.

The Tendency of Hyperthyroidism to Recur.-In cases of hyperthyroidism improvement or even apparent cure, while the patient remains in the hospital, is not conclusive evidence of the beneficence of the treatment, claims the American Journal of Surgery (Feb., 1921), whether it was by surgery, medicine or the X-ray. The symptoms may, and often do, recur when the patient returns to the environment in which they developed.

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Influence of Thyroid Function Suprarenals.-There is much evidence, tho not unanimous, Herring says (Endocrinology, October-December, 1920), that hyperthyroidism increases the size and weight of the suprarenals. There is some evidence that hyperthyroidism does, in the healthy animal, increase the epinephrin load of the chromophil tissues. A specific action of thyroid in stimulating the secretion of epinephrin and in sensitizing the structures amenable to its action, tho not improbable is not satisfactorily proved. Hypothyroidism is shown to have no effect on the epinephrin load of the suprarenals.

ETIOLOGY

DIAGNOSIS

The Diagnosis of Acute Abdominal Crises.Burgess (British Medical Journal, Dec. 11, 1920), in his two post-graduate lectures given in part, takes up the diagnosis of acute abdominal crises in a general sense, and considers, first of all, individually, the various symptoms and signs met with in such crises, attributing to each its relative value as a factor in diagnosis, and as an indication for treatment; and secondly, these same symptoms arranged in groups, such as are observed clinically in the different types of abdominal crises. The general symptoms include: (1) Various degrees of shock or collapse; (2) alterations in the frequency and character of the pulse; (3) changes in the temperature; (4) alterations in the type of respiration-"thoracic" type; (5) other symptoms, such as a dry and furred condition of the tongue, hiccough, strangury, and tenesmus. Speaking generally, one may say that, although these general symptoms are useful in directing attention to the possibility of a crisis having occurred, yet they give no clue to its nature, nor are they alone of much value as indications for treatment. It is, then, mainly upon the local symptoms and signs-those referable to the abdomen itself-that one must rely in deciding questions of diagnosis and treatment in any acute abdominal crisis. These include: (1) Abdominal pain; (2) cutaneous hyperalgesias ("viscerosensory" reflex); (3) tenderness, local and general; (4) nausea, vomiting; (5) muscular rigidity ("visceromotor" reflex); (6) abdominal distension; (7) presence of free gas in the peritoneal cavity; (8) presence of free fluid in the peritoneal cavity; (9) local abdominal or pelvic swelling; (10) certain changes ascertainable upon rectal examination. Before deciding in any given case presenting symptoms suggestive of an acute abdominal crisis that the cause is referable even to the abdomen at all, two fallacies in particular should be borne in mind: (a) The "crisis" met with in tabes dorsalis "gastric," "intestinal," and "renal." It should be a cardinal rule to test the kneejerk in every abdominal case. On the other hand, it must be realized that tabes does not preclude the coexistence of a true abdominal crisis and, further, that visceral analgesia which occurs in some tabetics and prevents the manifestation of pain, cutaneous hyperalgesia, tenderness, and rigidity, may render the recognition of such crisis a very difficult matter indeed. (b) The possibility of confusion between acute abdominal crises and acute intrathoracic diseases, especially acute basal pneumonia, acute diaphragmatic pleurisy, and acute pericarditis. This difficulty is sometimes a very real one, and surgeons of experience have

not infrequently opened the abdomen only to find the peritoneal cavity normal and the lesion an intrathoracic one. Whenever acute lobar pneumonia follows within twenty-four or fortyeight hours of an "early appendectomy," one cannot help but suspect that the pneumonia was the real cause of the abdominal symptoms and that the operation was unnecessary; when pneumonia is due to an operation, it is of the lobular or bronchopneumonia type. Confusion is particularly liable to arise in young children, since they cannot assist with a description of their symptoms, and since in them the physical signs of pneumonia are sometimes delayed for twenty-four or even forty-eight hours. Having excluded these possible fallacies, and having decided that one is dealing with a true abdominal crisis, the possible cause of the condition is next to be considered. For his own guidance, the writer is accustomed mentally to classify the causes into five groups: (1) The colics; (2) the perforations; (3) the hemor rhages; (4) the inflammations; (5) the obstructions. In conclusion, the writer emphasizes the importance of early diagnosis. The time that has elapsed between the onset of the attack and the opening of the abdomen is the real deciding factor in the ultimate issue of the case-far more so than the skill of the individual surgeon. He believes he speaks for all surgeons when he says that he infinitely prefers to meet in consultation the practitioner whose diagnosis, made in the early hours of the attack, is limited to "something gone seriously wrong in the belly" than one who, fortyeight hours later, can give a cut-and-dried and possibly perfectly correct description of what an operation will reveal.

The Diagnostic Value of the Renal Outlines in X-Ray Pictures.--Scott (British Medical Journal, September 11, 1920) summarizes as follows the method of determining the relation of abnormal shadows to the kidney: (1) The outline of the kidney must be seen. (2) An abnormal shadow lying outside this cannot be in the kidney. (3) If the shadow lies inside the limits of the outline, then it is necessary to compare the plate taken at full inspiration with one taken at full expiration. The respiratory excursion of the kidney is first measured, and the respiratory movements of the shadow under discussion are then compared. The direction of the movement of each is also noted. If the respiratory excursion and direction of the kidney and abnormal shadow are the same, the latter must be in connection with the kidney. A rule, therefore, can be formulated that if an abnormal shadow or shadows, no matter how small and insignificant they may be, lying inside the renal outline, move to the same extent and in the same direction as the kidney, they must be connected with it. This rule will apply to one or several shadows, and in this way it is quite easy to pick out from a number of shadows those that are of renal origin. In some cases the kidney may be fixed, and no respiratory excursion obtainable. If, however, it be