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RAFTER, Dr. J. A., Whiting, Kansas.
RANKIN, Dr. FRANCIS H., Newport, R. I.
RAYMOND, Dr. H. J., U. S. A., Alcatras Island, Cal.
READ, Dr. H. H., Halifax, N. S.
RIPLEY, Dr. John H., New York.
BOBERTS, Dr. M. Josiah, New York.
ROCKWELL, Dr. A. D., New York.
Roosa, Dr. D. B. St. John, New York.
Root, Dr. P. S., Monroe, Mich.

WENDT, Dr. E. C., New York.
WHITTAKER, Dr. James T., Cincinnati, O.
WILLIAMS, Dr. CORNELIUS, New York.
Wood, Dr. HALSEY L., Michigan.
WOODSIDE, Dr. John S., Flatbush, L. I., N. Y.
WYETH, Dr. JOHN A., New York.

SANDs, Dr. H. B., New York.
SATTERTHWAITE, Dr. T. E., New York.
SCHULTZE, Dr. R. C., New York.
SEARCY, Dr. J. T., Tuscaloosa, Ala.
SEXTON, Dr. SAMUEL, New York.
SHAFFER, Dr. Newton M., New York.
SHRADY, Dr. Geo, F., New York.
SIMMONS, Dr. DUANE B., Yokohama, Japan.
SPEER, Dr. A. T., Newark, O.
SPITZKA, Dr. E. C., New York.
STARR, Dr. M. ALLEN, New York.
STERNBERG, Dr. Geo. M., Surgeon, U.S.A.
STICKLER, Dr. J. W., Orange, N. J.
STILLMAN, Dr. Chas. F., New York.

Institutions and Societies from which Reports have

been received. AMERICAN MEDICAL ASSOCIATION. BELLEVUE HOSPITAL. CINCINNATI ACADEMY OF MEDICINE. CINCINNATI MEDICAL SOCIETY. CONNECTICUT MEDICAL SOCIETY. Cook County HOSPITAL, CHICAGO, ILL. GERMAN CONGRESS FOR INTERNAL MEDICINE. HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA. MANHATTAN EYE AND Ear HOSPITAL. MATERIA MEDICA SOCIETY. (New YORK.) MEDICAL AND CHIRURGICAL FACULTY OF THE STATE

OF MARYLAND.
MEDICAL SOCIETY OF THE COUNTY OF NEW YORK.
MEDICAL SOCIETY OF THE STATE OF NEW JERSEY.
MEDICAL SOCIETY OF THE STATE OF NEW YORK.
MEDICAL SOCIETY OF THE STATE OF PENNSYLVANIA.
NEW YORK ACADEMY OF MEDICINE.
NEW YORK PATHOLOGICAL SOCIETY.
NEW YORK SOCIETY OF GERMAN PHYSICIANS.
NEW YORK SURGICAL SOCIETY.
PRACTITIONERS' SOCIETY OF NEW YORK.
QUEEN CHARLOTTE's LYING-IN HOSPITAL, London,

Eng.
St. FRANCIS' HOSPITAL, New YORK.

Tait, Lawson, F.R.C.S., Birmingham, Eng.
TAYLOR, Dr. J. B., New York.
Thomson, Dr. Jos. C., Canton, China.
TYNDALE, Dr. J. HILGARD, New York.

VALENTINE, Dr. FERDINAND C., New York. VANCE, Dr. AP MORGAN, Louisville, Ky.

VOL. XXI.

JANUARY 7, 1882.

No. 1.

HONORARY MEMBER AND FX-PRESIDENT SOUTH CAROLINA MEDICAL

ASSOCIATION; SCRGEON TO THE EYE, EAR AND THROAT

average mortality among vaccinated patients was 4.32 Original Communications. per cent., while in the more recent epidemics, from

1870 to 1880, the average mortality among caccinated

patients was 12.52 per cent. The Prussian and EngA PLEA FOR IMPROVED VACCINATION.

lish records, although not offering so great a differ

ence, will serve to illustrate this point. From 1848 By S. BARUCH, M.D.,

to 1859 there were reported in Prussia 46,898 cases of small-pox, among which there was a mortality of 6

per cent. among the vaccinated. But in the records DEPARTMENT, X. E. DISPENSARY, NEW YORK.

from 1871 to 1872, of the Berlin small-pox hospitals, A RECENT editorial in this journal presents a succinct I find an average mortality of 14.55 per cent. among view of the merits of vaccination, and answers some the vaccinated. Again, the London small-pox hosof the arguments of the anti-vaccinationists with the pitals report, from 1836 to 1856, 9,000 cases, among irrefragable" logic of facts.” The writer says: “It which there was 5 per cent. mortality among the is becoming somewhat tiresome to have to reiter- vaccinated, while, from 1871 to 1878, they report ate the truths of vaccination, and it will sometimes 9,158 cases with a mortality of 10.93 per cent. among occur to us that the best way after all would be to the vaccinated. What is the cause of this increased leave the question alone and let the people find out mortality among the vaccinated during the past dethe facts themselves. But both humanity and a cade? To the unbiassed student of the history of pride in our profession forbid that anti-vaccination the recorded epidemics one pre-eminent cause must arguments should go unanswered, when popular igo present itself, viz., the neglect of Jenner's teachings. norance is plainly being imposed upon by them.” During Jenner's active work, and in the years im

It is gratifying to note that an influential journal mediately succeeding, the "golden rules” of the ilcalls attention to the importance of heeding the lustrious discoverer were scrupulously followed. influence of these people upon the public, who are His influence swayed the medical mind long after so readily entrapped by pseudophilanthropists of all his labors were brought to a close. Filled with the stripes. The busy practitioner is too prone to be- recollection of the dread scourge from which he was lieve that he has done his whole duty when he has liberating the world, medical men regarded his obtained pure (?) bovine virus and inserted it into every rule as imperative. Arm-to-arm vaccination, the arms of all the babies in his clientele. He regards with lymph carefully chosen from eighth-day puswith contempt the anti-vaccination agitation, char- tules, was the rule, and, without questioning its inacterizing it as the offspring of ignorance and fa- fallibility, it was obeyed. As the terrific nightnaticism, and refrains from studying their argu- mare, which had brooded over the profession until ments and statistics because he is satisfied that the Jenner dispelled it and infused hope in its stead, experience of the profession sustains him in con. faded from their recollection, and when the enemy tinuing the much-abused practice. In the course of seemed bereft of his power, their vigilance relaxed. a thorough study of the subject of vaccination, un- Modifications were introduced, various methods of dertaken while Chairman of the State Board of obtaining, preserving, and propagating lymph were Health of South Carolina, I had occasion to canvass adopted; mothers and nurses regarded themselves the arguments of the anti-vaccinationists, and I con- competent to perform this operation seemingly so fess that some of their claims are not without sub- trifling. It was not long ere the consequences of stantial basis. It can, for example, not be denied neglect and indifference made themselves felt. Holdthat a very large proportion of admissions-a large ing the view that the inadequacy of vaccination in majority in some small-pox hospitals—are cases bear- recent years is the cause of the imperfect protection ing vaccine-marks upon their arms, and that many afforded, I will enforce it by reference to several reof these cases succumb to the disease. Like all ex- cent reports of committees. tremists, the anti-vaccination people claim to receive In 1860 to 1864, Drs. Stevens, Buchanan, and from such statistics confirmation of their assertion Sanderson reported to the British Government that Jenner's grand discovery has proved unavail- (“Reynolds' System of Medicine,” vol. i., 171, Seaing. But they ignore the fact that Jenner claimed ton), that an examination of half a million vaccinated only the same immunity for the vaccinated which children revealed the startling fact that not more was possessed by those who had passed through than one child in eight was found to be so vaccinated small-pox. There is, however, much food for reflec- as to have the highest degree of protection that vaction in statistical tables. My recent investigation of cination is capable of affording; not one in three this subject demonstrated clearly to my mind not could, on the most indulgent estimate, be considered only the protective influence of vaccination against well protected. On page 151, Dr. Marson says: small-pox invasions, but also its ameliorating effect “Cases of small-pox have kept gradually increasing upon the type of the disease when contracted, and in numbers until they now amount to four-fifths (!) the diminution of the mortality thus wrought by it. of the admissions into small-pox hospitals.” On No fair-minded person could deny the latter espe- page 152, Dr. Marson also demonstrates that, out of cially. But I was also surprised to discover unsought 544 cases having four or more vaccine-marks, only evidence upon another point. A critical examina- one-half of one per cent. died of small-pox, and that tion of all the records of small-pox from 1818 to the mortality increased in an inverse ratio to the 1880 brought out the fact that, in the epidemics (of number and quality of the scars. which we have reliable data) from 1818 to 1870, the In the “Report of the British Army Medical Department for 1877" (p. 229), Surgeon-Major Archer, points with pride to its well-developed limbs and who took great pains to investigate and note the rounded outlines, deeming the intertrigo a matter of marks of all recruits examined by him, proves that no consequence-a trouble which is “natural to fat a large proportion of adults of the present generation babies.” I do not propose to enter into this subject are imperfectly vaccinated. Forty per cent. of the young as fully as its importance demands, because the recruits were insufficiently protected. He also shows literature of vaccination abounds with precise, mithat the liability to small-pox bears a distinct rela- nute, and reliable data. Regarding the selection of tion to the quality of the vaccination.

lymph, sufficient care is not exercised. Scabs are The same result has been shown by the “Report of frequently used. These ot rarely co

pus or the Hampstead and Homerton Small-Pox Hospital.” blood, or are obtained from inflamed surfaces, all of Dr. Bridges, in his report to the Local Government which not only offer serious impediments to sucBoard, divides the cases registered into four classes. cessful vaccination, but may also, as is well known,

excite constitutional or local disturbance of grave Hampstead Hospital, from 1876 to 1878.

character. In these days of mercenary traffic in all Class I.---Patients bearing marks of good vacci- things, human life is but too often regarded as nation. The death-rate was 57 per 1,000; ranging, naught when placed in the scale against profit. The however, from 31 per 1,000 in patients with four tottering tenements, the rotten ships, the rusty marks or more, to 95 per 1,000 in patients with one boilers and frail bridges which have sent their vicmark or more.

tims into eternity, bear witness to this fact. Is it not Class II.-Patients bearing marks of indifferent possible-yes, probable--that this mercenary spirit quality. The death-rate in this class was 113 per has touched the dealers in “ vaccine virus" and ren1,000; ranging from 58 per 1,000 in patients with four dered them careless regarding the maintenance of or more such marks, to 143 per 1,000 in patients with its purity and efficiency? When we remember the one or more such marks.

extreme care necessary for the preservation of the CLASS III.-Patients stated to have been vacci- human and the cultivation of the animal “ virus," nated, but showing no evidence. The death-rate the skill and familiarity with the entire subject dewas 320 per 1,000.

manded of those who are engaged in this work, we CLASS IV.-Unvaccinated patients. Death-rate cannot be too careful with reference to the source 468 per 1,000.

of our supply. In this matter we are at the mercy Homerton Hospital, from 1871 to 1878, same classifi

of the dealers, among whom there are doubtless cation.

who realize its importance, and who are scrumany

pulously honest in the recommendation of their CLASS I. showed a death-rate of 33 per 1,000; rang- wares; and yet I have observed that, out of thirtying from 15 per 1,000 in patients with four good five vaccinations made by myself last winter, with marks, to 39 per 1,000 with one mark.

bovine “virus" purchased from one of the most reCLASS II. showed a death-rate of 111 per 1,000; | liable drug-houses in this city, I had no less than ranging from 55 per 1,000 to patients with four marks, ten “irregular” vesicles, which took on an inflamto 158 per 1,000 in those with one mark.

matory action, resulting in fibrinous deposits and CLASS III. gave a death-rate of 272 per 1,000. extensive erysipeloid blush over arm and shoulder. Class IV. gave a death-rate of 452 per 1,000. I have a vivid recollection of two babes whose arms

Here we have carefully collated data, which prove and shoulders were enormously swollen, brawny, conclusively that the influence of vaccination upon tense, and in one of whom constitutional disturbance the mortality of, and pari passu upon the liability to was alarming. These children, who had been in small-pox, is in an unmistakably direct ratio to the perfect health up to the time of vaccination, were quality of the vaccination, diminishing with the im- vaccinated by experienced and justly distinguished perfect and increasing with the perfect manner in physicians, who would neglect no precaution with which this operation has been done.

reference to the purity of the “ virus” or its careful It behooves every physician to ask himself what insertion. In the majority of cases referred to share he bears in the perpetuation of the imperfect there was no other cause to which the systemic and vaccination which has evidently been practised dur- local disturbances could be charged but some deing the past twenty or thirty years.

How many

fect in the “ virus." All physicians will readily medical men do now devote the time and attention recall similar instances in their own experience. necessary to the selection of the lymph, the exami- According to Seaton, a vaccination presenting any nation of the vaccinee, the proper inoculation of the deviation from the perfect character of the vesicle and lymph, the inquiry regarding the result, and the re- the regular development of the areola is not to be relied vaccination of imperfectly matured cases and cases on as protective against small-po.c." "A spoiled and whose protection is rendered doubtful by complicat- broken appearance of the vesicle, which is frequently ing inflammatory conditions ?

on the eighth day ascribed to rubbing or mechani. I do not know a single physician who is a true dis- cal irritation, is often really an irregularity arising ciple of Jenner in this respect, or who carefully fol- from one or other of these causes (either the use of lows Marson's and Seaton's directions, so ably and lymph not well chosen, or to something amiss in the earnestly inculcated in their works on this subject. state of the child vaccinated).” How many of our Glaring deviations from health in the infant are not vaccinations approach in their results the standard overlooked, but there are some obscure ailments of this authority? And yet, his large experience, which should be inquired after. So trifling a trou- sustained by others of equal eminence, induces him ble, for instance, as intertrigo, is regarded by Seaton to lay down the above “one important, practical as a bar to vaccination (unless in the presence of fact." How many physicians resort to revaccinasmall-pox exposure). Many infants presenting a tion in cases of inflamed or otherwise irregular robust appearance are affected by this ailment in vesicles ? I know not one who would have the the lower part of the body, where it is hidden from hardihood to propose revaccination to the mother the eye of the physician. To the careful physician's of a child which has recently passed through illness inquiry regarding the health of the babe, the mother of three or four weeks, produced by vaccination of 'pure (?) virus.” The mother having a fear of the inoculated. But I do hold that the good old Jenrepetition of sleepless nights and anxious days with nerian plan of arm-to-arm vaccination should be reher fretting babe before her, will almost surely de- sorted to whenever practicable. That it is often cline. I have heard mothers say they would risk practicable to the painstaking physician no one will a liability to small-pox rather than expose their doubt. children to a repetition of the ordeal.

The remedies for the existing imperfect protecWith regard to the method of operating, I need tion against small.pox would, in my judgment, be not dwell upon the well-known fact that mothers found : and nurses often take upon themselves this work, First.-In renewed attention to the selection of deeming it only necessary to scratch the surface and proper eighth-day lymph, more careful cultivation apply the “virus,” and regarding the efficiency of of bovine “virus,” greater care in both cases to the procedure in exact proportions to the amount of scrutinizing and tracing it to a pure source. Each irritation and the size of the vesicle they have pro- supply should be tested on one healthy vaccinee duced. Nor are physicians as careful with this before it is extensively inoculated. Especially is this seemingly trifling procedure as its real importance precaution needed in the use of bovine "virus," demands. We are too prone to lose sight of the fact which not rarely produces local irritation, whose that the imperfect execution of this operation may effect is pernicious upon the protective influence at some future time result in loss of life and destruc- afforded by it. tion of happiness, which the imperfect performance Second. Too much attention cannot be given to of any one of the capital operations could not ap- the methods of vaccination now in vogue—the techproach in direness. Jenner, Seaton, and others de- nique of this simple procedure. Those who are not vote page upon page to the description of this familiar with the writings upon this subject by Marseemingly slight operation, to pointing out the son and Seaton, would do well to study their valucauses of failure and modes of avoiding the latter. able suggestions and elaborate directions, especially And yet how many students are taught these in- with reference to the watchfulness necessary when valuable lessons ? Marson says with much feeling : the vesicle is maturing or matured. The care pre“Great care is given to teaching and learning the cision, and attentive regard for minutiæ which the capital operations, as they are called, which not one men of Jenner's day and the time immediately sucpractitioner in twenty through the whole country ceeding bestowed upon this seemingly trivial work, ever performs; no care, or next to none, to teach- may be profitably emulated by the present generaing and learning the other (vaccination), which tion of medical men, if they would protect their nearly all, when in practice, will have to perform fellow-men against the terrible scourge which now frequently. As medical and surgical practitioners, and then invades our cities and populous country our object should be to save all the lives we can by districts. our art, no matter by what means; and if a little Third.-A more thorough instruction of medical operation-little, apparently, in practice, but very students in the details of obtaining supplies of vacimportant in its results-well performed can save cine material, in the methods of its propagation, in many lives, as most certainly it can, and prevent the technique of vaccination, in the diagnosis of the much suffering and sorrow, it should surely always true from the spurious vaccine vesicle, is imperabe done with the greatest care and in the best known tively demanded. The medical student cannot be way. The success of all operations depends on nice too deeply impressed with the idea that this operacare and management. Operations for hernia and tion, slight as it may seem, will confer greater benefor stone, for instance, if roughly, carelessly, and fits to the people under his care than all the skill he badly done, end badly; so it is with vaccination; may acquire in surgery. The admirable instructions and, so far as the public are concerned, it is quite as on vaccination, written by Mr. Simon, for guidance of objectionable to them, no doubt, to die of small-pox, “ vaccinators under contract,” by order of the Privy because they have been carelessly and badly vacci- Council, July 29, 1871, are a model upon which nated, as it would be to them to die of hernia or teachers may successfully construct their lectures stone, because the operations for these complaints on this subject. No medical student should be al. respectively had been badly performed. In the lat- lowed to graduate who does not exhibit a full apter case the day of retribution would come imme- preciation of the importance of vaccination and a diately; in the former, unfortunately for its correc- thorough knowledge of all its details. tion, it is delayed perhaps for twenty years or more; Fourth.--I would suggest the inauguration of a otherwise it would soon be set right.”

new specialty. The “ vaccinator” would in our I have quoted somewhat at length from this ex-" large cities (which are the habitat of most specialcellent writer, because his life has been spent in the ists) prove far more useful to the public than many effort to counteract the evils of bad vaccination. It of the specialists who now minister to its numerous would appear from the writings of Seaton that the “ special ills.” A vast deal of good would be accomdegeneration which has been attributed to the “vi- plished by men who, like Marson and Seaton, have rus," on account of its long descent through the studied the subject of vaccination in all its details, human body, is really a myth, and that this charge and who would relieve the general practitioner of all of degeneration belongs more justly to the technique care in this important matter. A large number of of vaccination.

educated physicians may devote themselves to this Marson and Seaton affirm that they have found branch of study and practice with credit and profit virus of undoubted Jennerian descent, successful in to themselves and to the profession. As it now the production of true Jennerian vesicles after trans- stands, the general practitioner obtains but little mission through a period of fifty years. I do not thanks, frequently not even compensation (forit seems propose to enter the lists against the advocates of to be by many regarded as a complement to the labor bovine virus. Far be it from me, for this substitute case), for this work. The opprobrium, on the confor the humanized lymph is extremely useful for trary, resulting from the insufficient protection due preservation and transportation, and affords good to various causes over which the busy doctor bas protection when genuine and carefully guarded and but little control, is unstinting. The greatest bene

.

AIKEN, 8. c.

fit, however, would accrue from this departure. Just CASE XXIX.-Went to Colorado, expecting to esas in other departments vast results have been tablish himself in business there; but, finding that achieved by special study, so will in time be accu- the climate disagreed with him, returned to Aiken, mulated large stores of statistical information and where he passed the winter. practical improvements in the methods of cultivat- April 28th.--Pulse, 88 ; temperature, 98° ; weight, ing the vaccine-lymph and transmitting the vaccine 134. Has had no relapse, goes about without redisease in its purity and genuine type. Let it be gard to weather, and has the appearance of a perfectly borne in mind that the grand aim of medicine, the healthy man. On the right side there is still dul“stamping out” of small-pox, has thus far not been ness over the upper third of the scapula and over reached. On the contrary, we are confronted daily the corresponding interscapular space. Respiration by failures, and taunted by the frequent recurrence somewhat jerking, but in other respects normal. of small-pox epidemics. This failure of vaccination CASE XLI.—Passed the summer in West Virginia, to accomplish its alleged mission is converting a where she was exposed to intense heat, combined with credulous public to the doctrines of the anti-vacci- a high degree of relative humidity, which caused nationists, and thus adding fuel to the disease. I her to lose much of what she had gained at Aiken. have attempted to demonstrate the cause of failure On her arrival (November 19th) she was pale, thin, and to point out the remedy. The immeasurable and decidedly cachectic in appearance. Pulse, 102; importance of this subject demands earnest and im- temperature ranging from 99° in the morning to 101° mediate action on the part of the medical profession. in the evening. Over the upper portion of the right 144 West FORTY-THIRD STREET, NEW YORK. }

lung there is diminished resonance in front, with dulness behind over the upper two-thirds of the scapula. Respiration bronchial, with prolonged ex

pirium. REPORT OF CASES OF PHTHISIS

May 13th.-Patient had a slight hemorrhage in TREATED DURING 1880-1881.

February, and in April an attack of diarrhæa. In

every other respect she has done well and is much By W. H. GEDDINGS, M.D.,

improved. Pulse, 96; temperature ranges from

98.50° to 99.2°. Cough is slight, and the expectora(Continued from THE MEDICAL RECORD. November 15, 1879, October tion does not exceed one ounce in twenty-four hours. 30 and November 6, 1880.)

Over the right front there is dulness above and Of the cases described in my report for 1878–79, under the clavicle, with harsh respiration, but withand 1879–80, a few returned to Aiken, and thus af- out râles. Behind there is diminished resonance forded me the opportunity of presenting the contin- half down the scapula, with feeble respiration. uation of their case histories.

Result.-It will be observed that this patient reCase II.-Succumbed to his disease after having gained much of what she had lost during the sumpassed seven seasons at Aiken with more or less im- mer, increasing in weight and improving in strength, provement.

together with diminution in the extent of the disCASE V.—The improvement noted in this case has continued, but, being of a rather nervous tempera- CASE XLIII.—This patient, in whom the disease ment, could not be induced to submit to an exami- has remained quiescent for years, had some little nation. He has now enjoyed good health since May, twinging of sputa in February, but remains quite 1879.

well and pursues her accustomed avocations. Case VI.-This patient returned to Aiken, but did CASE XLIV.-Passed the winter in Aiken, but did not consult me. She presents the appearance of a not report until January 7th. His temperature was girl in perfect health, and her mother reports that normal, and his weight had increased to 135 pounds, she is doing well.

a gain of 9 pounds. His face had the ruddy hue of CASE XV.—Continues to enjoy perfect health. health, and, with the exception of a limited area of

CASE XVII.- November 15th, pulse 92, temperature dulness, there were no evidences of disease. In a let99.4. Cough slight, with a small amount of expec- ter from him, dated October 23, 1881, he states that toration. There is still diminished resonance over during the last three months he has filled the arduthe upper portion of the left chest, extending from ous duties of cashier in a large mercantile establishclavicle to third rib. Respiration somewhat feeble, ment in Massachusetts, without losing a single day with an occasional squeak, the result of an acute through sickness. He still remains free from coughi. bronchial catarrh contracted during the journey .This patient was sent to Aiken as a dernier ressort, his South. Posteriorly, there is dulness over suprascap- 'physician stating that he might possibly improve, ular region, the respiration being roughened, with but intimating that his case was a desperate one. prolonged expirium.

CASE XLVII.—Returned to Aiken, but failed to May 4th.-Has passed the winter without present himself for examination. His appearance lapse. Her color is fresh and ruddy; her flesh is was that of a well man, and his physician informs firm, and her weight 1301 pounds, which is more than me that, with the exception of one hemorrhage, he she ever weighed in perfect health. The only re- has had no trouble since his departure from Aiken minder of her former disease is an occasional hack. the previous spring. The old area of dulness over the left apex is still CASE LI.—Passed the summer at Bethlehem, present, but the more recent one to the outer side N. H., where he remained quite well, and returned of the heart has entirely disappeared. No change to Aiken in November. His color was good, his in the condition of the lung posteriorly. This pa- | pulse and tempe ture normal, and his weight 142 tient has purchased a residence at Aiken, and intends pounds. Cough very slight, with a trifling amount making it her future home.

of expectoration in the early morning. Physical exCASE XXIII.-Wintered in Aiken, but did so well amination revealed no symptoms of disease other that he did not require the advice of a physician. than a limited amount of dulness over the right suHe looked quite robust, and appeared to be in per- praclavicular region. fect health.

May 1st.-Has gone through the winter without

ease.

any re

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