right and should not injure anybody. He said he was opposed to having the society state in its wisdom that it knew more than the United States Government and he believed that it was creating a hardship if the law as proposed was signed. If one wished to establish such sanatoria he asked why the Supervisors could not be approached and persuaded to allow it done.

Dr. H. M. KING of Liberty, N. Y., said that consump

tion was not to be feared at all in the same sense that smallpox was, for it depended for its development upon so many factors besides the tubercle bacillus, such as the poorlyventilated offices, the badly arranged residences of the working people and many other factors too numerous to mention. The mere fact that a consumptive was in our midst was no reason why other people should be affected, provided the consumptive be properly instructed in the care of himself. He knew of no stronger argument in this regard than that during the past year, at the Loomis Sanatorium, there were several children, children of consumptive invalids under treatment, and they were there without danger to themselves. It seemed necessary now to combat the ridiculous ostracism to which the consumptive invalid was exposed. He said the crusade against the consumptive started in the West, where a law was passed in several cities against the consumptive and he said it was absurd and unjust to deal in this way with the individual who had contracted consumption. It was Naegli who found, among autopsies performed on people who died from all kinds of diseases, that 98 per cent. of all invalids over thirty years of age had in some parts of the body evidences of tuberculosis; that only one in seven died from consumption, while one in three had pronounced lesions and four out of seven recovered from the disease with healed lesions.

Dr. H. W. BERG said he did not believe the profession at large imagined the consumptive insane or mentally unsound and that certainly the physicians of this city did not have such an opinion, and, therefore, it appeared to him that the gentleman referred to in the paper, a man practically unknown, had acted as a phantom and Dr. Knopf was attacking an adversary unworthy of his steel. He warned the society not to resolve anything as proposed by Dr. Knopf if they did not wish to make themselves ridiculous. Regarding the question of the mental state of the consumptive, it must be remembered that some of the best, wisest, and brainiest men were consumptive and, as cuoted from Naegli, 98 per cent. of human beings had consumption, although often dying of other diseases. He asked if 98 per cent. of all men were insane. No human being with any regard for what he writes would say that consumptives were mentally insane. He said that so far as the Goodsell-Bedell bill, or all legislation in fact was concerned, all emanated from the doctors and not from the lawyers. He said that no president of the United States, no governor of any State, no mayor, nor any legislative body ever proposed or passed a law of any kind or description against the consumptive, without being led thereto by action of physicians. Every time action had been taken it had been backed by eminent members of the profession. He believed the laity had mistaken the terms contagious and communicable, thinking they were synonymous. By communicability one meant taking some emanation from a sick body and absorbing it into one's own. He said that consumption was not contagious but communicable. The ignorant laity think, when legislative bodies legislate against the communicability of something, that they are legislating against the contagiousness of something.

Mr. E. T. DEVINE, Secretary of Charity Organization Society said that being neither a physician nor a jurist, he could approach the subject in an unprejudiced manner. He wished to say a word regarding the central feature of the paper and also upon the wisdom of a particular piece of legislation. It seemed to him that the doctor was

speaking ironically when he stated that all the bills that got through the legislature were passed for the public good; occasionally, he said, things slipped through the legislature for other reasons, and as an example of this, he briefly referred to what had recently happened above Tuxedo Park, where a man owned a piece of land adjoining a club, and who wished to dispose of it at an exorbitant price to this club. He wanted to make it absolutely necessary that the club should purchase it and, therefore, he came to the Health Commissioner of New York City and said, "I have a piece of land well located and I am going to offer it to you free for a certain time if you will promise to use it for a camp for consumptives." The Health Department was anxious to get the land for that purpose and so closed the offer. The object of this was to make it necessary for the club to buy the land at his price. The club refused to pay, but they went to the legislature and asked them to pass a bill making it impossible to build such a camp without the consent of the township, making it necessary for them to get the consent of the township as well as that of the Board of Health. The Assembly at Albany, to their credit, vetoed this bill, but within an hour of the time they vetoed it a friend of the Governor appeared on the floor, asked them to reconsider their vote, which they did and the bill was passed. He said that was the way the Goodsell-Bedell bill was passed, and he did not think it was passed for the interest of the consumptive but in the interest of the State. This was not simply an instance of recognizing local government, for we have a requirement which stated that the State Board of Health must also give its consent for the erection of such an institution. they both have a voice in the matter, and when you add to this the consent of the township and the county authorities, he said, you must see how impossible it was to build such a camp. He said it would have been impossible for Dr. Trudeauor Dr. Loomis to have built their sanatoria if the Goodsell Bedell bill had been upon the statute books when these institutions were built. He hoped that when the opportunity presented itself the society would aid in the repeal of this measure.

Mr. WILLIAM R. A. KOEHL endorsed very heartily the views expressed by Mr. Demond, and he regretted very much this semi-political discussion in regard to the whole matter. It was regrettable that the speaker of the evening should refer to the Governor of the State as "our most distinguished Governor," for the Governor of our State did not make a bill, but he was a mere incident; the President of the United States was a mere incident to a bill. He said a man may be condemned whether he vetoes a bill or not. He was opposed to the resolution in its present form. He said he was not opposed to the consumptive and wished to help along the interests of the consumptive. He believed the matter should be laid before a committee for action, and he moved that it be referred to a Committee of Five to be appointed by the Chair and who should report back to the society at its next meeting.

(It was then further amended that the resolution be referred to the Board of Trustees for action. This was carried.)

Dr. S. A. Knopf closed the discussion and said that he only wished that Mr. Demond's statement that "all laws were good" was true. In regard to the difference which existed between consumption and smallpox he would gladly enlighten Mr. Demond by saying that the latter is a dangerous contagious disease, the former simply a communicable disease, and he illustrated the difference by saying that a well-conducted sanatorium for consumptives was the surest place for a well person not to contract the disease, while in the smallpox hospital, no matter how well kept, one would be sure to contract the disease unless vaccinated and revaccinated. There is no danger

in associating with a clean, conscientious consumptive, there is always danger in associating with a smallpox patient.

Mr. Demond, Dr. Knopf said, had made the statement that there was no such a thing as hardships imposed upon the consumptive. He evidently has had no experience with consumptives. To realize the hardships which are so often unjustly imposed upon the pulmonary invalids one must have been touched by the presence of consump

New Instruments.

A NEW FEMALE URINAL.
BY FRIEDRICH GROSSE, M.D.,
NEW YORK.

MRS. X. came under my treatment with a carcinomatous destruction of the bladder wall and vagina, ausing incontinence of urine. She had two urinals of the well-known shapes, but they did not answer,

then one will feel how greatly the consumptive deserves our sympathy.

In answer to Dr. Berg's criticism for having taken notice of an article written by a man unknown to the profession, Dr. Knopf said he thought it neither kind nor just to ignore the author of a work because he was not well enough known by the profession. Every well-known author must have been unknown at one time of his life. The fact alone that what Dr. Saxe wrote had appeared in two issues of the New York Medical Journal justified the consideration of the article and the author. Extracts of Dr. Saxe's article had been copied and recopied, not only in many medical, but also in quite a number of lay papers, and Dr. Knopf said that he had letters in his possession which showed the fruits of spreading such ideas. Furthermore, Dr. Saxe was not the only medical man afflicted with phthisiophobia, and when such statements were published as those promulgated by that author, or by other physicians or laymen, Dr. Knopf would always consider it his duty to protest against them.

In regard to the Goodsell-Bedell law, he could only repeat that resolutions were passed condemning it, not only by the Academy of Medicine, but also by numerous other medical societies of this city and State, besides the protests mentioned in his paper from the Charity Organization Society and the Masonic fraternity.

As a reply to Dr. Berg's accusation that Dr. Knopf was largely responsible for the compulsory reporting of tuberculous cases in this country, he would wish to say that he had always advocated what might be called a facultative, but not a compulsory registration. The Health Board of the City of New York requests that the physician reports the name, age, sex, and residence of the tuberculous patient, and whether there are any other members in the family afflicted, and asks if the attending physician wishes that an inspector from the Health Department should visit the patient's residence. If the attending physician does not desire to have this done there will be no interference. Surely such registration did not imply any hardship to the patient, his family, or his physician, but it was a valuable aid to statistical science, it told of the whereabouts of consumptives and of the districts which were particularly invaded by tuberculosis. Nearly all medical men favored such registration, and Dr. Knopf said that he had met few who would not wish to comply willingly with such regulations.

Dr. Knopf again asked the society to aid in the repeal of the Goodsell-Bedell law, and thought it wise to consider the steps to be taken in this matter quietly in special committees made up of lawyers and physicians. To combat the private phthisiophobia, which he believed existed to a most alarming extent, he would urge the authorities to give a better example and be helpful in educating the people at large to the fact that the conscientious consumptive is as safe an individual to associate with as any well person.

Officers Elected.-President, Theodore Sutro; VicePresident, Dr. Carl Beck; Treasurer, D. McLean Shaw; Recording Secretary, John C. West; Corresponding Secretary, Alfred E. Ommen. Trustees, Drs. Edward F. Brush, Frank Furguson, E. J. Palmer, and C. A. Ramdohr; Messrs. George C. Andrews, Charles P. Blaney, Charles M. Demond, Frederick B. House, and Henry Melville.

nent leaking of the urinals had given rise to the worst inflammation of the skin I ever saw. The external sexual organs and neighboring regions were highly eczematous, ulcerated, and, in addition, bedsores occupied the dependent parts. The minutest shifting of the urinal exaggerated the apparently intense pains. The patient was so exhausted from lack of sleep and appetite and terrible suffering, that death seemed to be a question of only a few days.

Although the family tried to keep her dry and clean, the offensive smell was almost unbearable. Everything was done to alleviate her condition, and finally I devised an apparatus which, on being in

serted into the vagina, could drain away the fluids without touching even the labia. This apparatus consisted of an annular brim of a watch spring, about one and one-half inches in diameter, covered with rubber dam, and attached to it a small bag of the same soft material, the tapered end of which was fastened to hard-rubber piece which allowed a rubber pipe to be drawn over it, to lead off the discharges into a vessel below the bed.

a

The apparatus was easy to introduce, caused no complaints whatever, and worked excellently, so that the patient lay absolutely dry, and could be kept clean. Although the smell had penetrated

the whole apartment, it was entirely banished. The inflamed skin soon became healed and the patient gained in strength and flesh, as far as the cancer permitted. Not long afterward I was surprised to find the sufferer out of bed, sitting in a chair, with the apparatus on. She had bound the bottle of one of her old urinals to her leg, and the pipe of the little bag connected with it. She could take it out, clean it, and introduce it herself without any difficulty.

Incident to the splendid result in this case, I tried it later with women whom I treated with ichthyol tampons, to prevent the cloths from being soiled, the tapes of the balls being put into the bag. As the amount of discharge in such cases was small, I had the end of the bag closed, and a little eye attached to it, through which, by means of a wool thread, the bag could be fastened to the thigh. All the women highly appreciated the new instrument, and one of them suggested that it would do the same service during menstruation. I followed the idea and tried it in about fifty cases, in all of which it gave satisfaction; none of the women had any

inconvenience and all preferred it to the sanitary napkin.

The diameter of the brim of the instrument varies according to the width of the vagina, and the length of the bag of the closed variety according to the quantity of fluid. In cases of incontinence of urine, the apparatus has to be used with a drainage pipe and a reservoir like the old urinals.

The insertion is done by the woman herself, introducing the ring about three inches into the vagina. A slight traction with the bag, in an angle of forty-five degrees, will bring it behind the hymenal ring, where a slight resistance will give the signal to stop, and the instrument will rest safely. A little stronger traction in different directions will remove it without difficulty.

The apparatus is superior to the common urinal, by, first, being incomparably lighter, the weight being only ten grams or so; second, adhering to the body without bandages; third, closing absolutely, provided the proper size is taken, and avoiding even moistening the labia majora. All women stated that in case of menstruation it was more comfortable than the bandages and caused no irritation whatever.

It will certainly be of great benefit in cases of permanent irrigation of the internal sexualia, in which the affluent catheter may be introduced by a hole cut into the bag, the wash will have its exit by the mentioned rubber outflow.

The instrument is inferior to the common urinal by being unavailable in the case of a virgin, and in that of incontinence of nervous or muscular origin. 65 SECOND STREET.

INFECTIOUS DISEASES, THEIR ETIOLOGY, DIAGNOSIS AND TREATMENT. By G. H. ROGERS and M. S. GABRIEL, M.D. 8vo, 874 pages. Illustrated. Lea Brothers & Co, GESAMMELTE ABHANDLUNGEN ÜBER ZUCKERBILDUNG IN DER LEBER. Von Prof. Dr. J. SEEGEN. 8vo, 492 pages. August Hirschwald, Berlin.

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OPERATIONEN AM OHR. Von Dr. B. HEINE. Mit 29 abbildungen im Text und 7 Tafeln. 8vo, 178 pages. S. Karger, Berlin. Price, M. 6.

307

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By P. LockIllustrated.

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【A Manual of Bacteriology. By HERBERT U. WILLIAMS, M.D. Third edition, 8vo, 351 pages. P. Blakiston's Son & Co.

PAUL GUTTMANN'S LEHRBUCH DER KLINISCHEN UNTERSUCHUNGS-METHODEN BRUST- UND UNTERLEIBS-ORGANE. Von Dr. FELIX KLEMPERER. 8vo. 529 pages. August Hirschwald, Berlin.

-HIRTZ in the Clinical Review.

Ethyl Anesthesia.-Chloride of ethyl anesthesia is easy and rapid and free from discomforts and danger. The fluid should be poured upon a mask or compress, a drachm or so at a time, and inhaled deeply. If the dose is repeated at intervals of five minutes, seldom more than an ounce is required. Anæsthesia results rapidly in about three minutes, and is indicated by muscular relaxation, sometimes by a dilatation of the pupils and loss of corneal reflex. There is no period of initial excitement, depression of heart, or respiration. There is seldom nausea or other ill effects. It is ill adapted to lung operations, but may be used to advantage as a preliminary to ether chloroform or ether. -VANVERTS.

The Prevention of Chloroform Accidents.-Felchenfeld has made some recent additions to his suggestion that tincture of strophantus should be given in frequent fivedrop doses for two or three days prior to chloroform

anæsthesia, in order to strengthen the heart action. He has recently insisted on the importance of frequent examinations of the heart before the administration of chloroform, even though the organ is found sound at the primary examination. In the case of a strong and robust man, preliminary strengthening of the heart is quite unnecessary. In case of nervous irritability of the heart indicated by dulness of cardiac sounds, by a somewhat diffused and indistinct apex beat, and by a small and very rapid pulse, the author would give small doses, not more than 5 drops, of tincture of strophantus and tincture of digitalis three times daily, for some days before the operation. The good effects of this treatment are shown by a reduced pulse rate, less mental depression, and anxiety, improved appetite and good sleep. The pulse rate, it is stated, should be reduced to 80, at the highest, before a subject of cardiac irritability can be chloroformed without risk. In a second group of cases, in which there is a distinct evidence of muscular degeneration varying from slight forms of muscular weakness to grave myocarditis, the author would endeavor to fortify the flagging heart and to improve the rapid and irregular pulse; and with such object in view would substitute for the first described method of treatment warm baths, carbonic acid baths, and injection of strychnine; the administration of digitalis being continued in the form of infusion. In cases of this kind, ether should be used as the anesthetic in preference to chloroform. The most difficult cases to deal with are those of hypertrophy of the cardiac muscles, which need careful prophylactic treatment, and in which the action of the anesthetic should be assisted by an injection of morphine at the seat of operation.

-Medical Age.

Typhoid Spine.-J. W. Cannon describes his own case of typhoid fever. Ten days after a relapse of his case, in turning over in bed a sharp pain was suddenly experienced in the lumbar region of the spine. For more than two months it was impossible for him to assume a sitting posture, so great was the pain induced. In turning over in bed he had to be very careful and use every precaution to keep the shoulders and hips moving at the same time to prevent any rotary motion of the spine. It is evident that the initial attack was caused by strain in turning over in bed. The pain was not unlike a sudden "crick," so often described by men engaged in lifting heavy weights. The point of injury was felt to be about the fourth and fifth lumbar articulation whence the acute spasmodic pains radiated. The author feels sure that there was periostitis of the anterior and lateral parts of the vertebræ, the inflammation extending to the ligaments, deep fascia and muscular attachments—neuritis, due to thickening of the periosteum, and injury to the nerves as they escape from the intervertebral foramen. Morphine, chloral, and bromides were of no practical benefit, nor were heat, massage, and electricity. Rest is the best treatment, and the more strictly adhered to the better. Recovery has at last been established with the exception of some weakness of the spine and slight tenderness.—Medical Herald.

contain half a dose apiece, two being taken at one time, and followed by half a glass of cold water. The author has not met with any disagreeable results from the use of this formula, and has found it most useful in cases which there is simply a swelling of the subcutaneous tissue presenting well-marked fluctuation, without redness or pain. He has treated such swellings in the perineum, the axilla and about the neck and caused their entire disappearance, though at the commencement of treatment there was unmistakably a drachm of fluid pus present. Annals of Gynecology and Pediatry.

The Relation of Hysteria to the Female Genitals.— Voss points out that the tendency of modern gynecologists is to modify the older view that hysteria was to a large extent founded on abnormalities of the pelvic organs. It is more particularly the neurologists, whose observations show that hysteria and the female genital system do not possess essential causative inter-relationship, while on the other hand gynecologists also have found that many conditions formerly believed to underly nervous disturbances have nothing in common with them, and that symptoms supposed to have a sexual etiology were of purely neurotic nature. The author's observations on ninety-six patients, showing hysterical symptoms, revealed sexual abnormalities in only nine. Of these, two were congenital malformations, and in only two of the entire number could any connection with the nervous condition be traced. The author believes that hysteria does not arise from affections of the female genitals oftener than from other morbid conditions. There are, however, nervous symptoms dependent on the genitals which simulate hysteria, such as reflex neuritis, neuralgia of the pelvic plexus and sciatic nerve, sacralgia, etc., but they are of direct and not of reflex origin. Most of the neuroses coming under the gynecologist's care are not true hysterias, and rarely offer the typical symptoms of disturbances of sensibility, pressure points, convulsive seizures, etc., but the diagnosis must be made chiefly on the history and the discrepancy between the subjective symptoms and the slight objective lesion. When any serious condition does not appear likely it is better in such cases to refrain from internal examination. The possible consequences of even slight operative procedures must not be underestimated, as even the narcosis alone may be of moment in those of neurotic predisposition.—Monatsschrift für Geburtshilfe und Gynäkologie.

to the Surgeon-General, U. S. Marine Hospital Service, during the week ended December 19, 1903:

Vol. 65, No. 2. Whole No. 1731.

Original Articles.

ETIOLOGY OF RHEUMATISM: OBSCURITY, INSIDIOUSNESS, PREVENTION, AND MANAGEMENT IN CHILDHOOD.

BY JOSEPH E. WINTERS, M.D..

NEW YORK.

PROFESSOR OF THE DISEASES OF CHILDREN, CORNELL UNIVERSITY MEDICAL COLLEGE.

RHEUMATISM is caused by non-neutralized acidproducts of proteid metabolism. It is cured by basic constituents of food.

Salicylate of soda from oil of wintergreen is a specific for acute active manifestations; cure is by neutralization in tissue fluids and cells of acids of proteid metabolism by bases abundant in certain articles of diet.

Every disease in its most pronounced typical form, has one unequivocal, absolutely diagnostic, pathognomonic In rheumatism this is profuse, symptom. Sour-smelling, acid perspiration. The normally alkaline saliva becomes acid, the urine is hyperacid, the fæces become acid. This condition belongs exclusively to rheumatism.

Vital processes of tissue cells are dependent upon alkaline tissue fluids.

In the normal state, acids of metabolism are immediately neutralized by basis held in organic combination with the proteid, and by alkali-carbonates from oxidation of vegetable acids.

In pathological conditions the first of the reserve alkalies to be drawn upon for neutralization of acids, are those of the blood. Reduction in alkalescence of blood, causes disintegration of red blood cells.

Sodium and potassium compounds are the chief elements in maintaining alkalescence of the blood. In aggravated rheumatic states, sodium carbonate of the plasma is decomposed, carbonic acid set free. Sodium transports carbonic acid to the lungs, where it is eliminated. Accumulation of carbonic acid in the blood, and in all fluids and cells of the body, shuts off oxidation.

Menacing symptoms in rheumatism are due to rapid large withdrawal from blood of the basic element, sodium; fatal reduction in alkalescence of blood; liberation of carbonic acid; arrest of detoxicating oxidative processes.

With prolonged gradual disarrangement, as in unremitting chronic states, the most resistant fixed alkalies of bone tissue are attacked; the osseous frame-work undermined; osteo- or rheumatoid arthritis.

This explains rheumatism from muscular and articular soreness following unusual exercise, with sudden checking of elimination, to rheumatic anæmia, and rheumatic hyperpyrexia. It also makes it clear why there is no line of separation between cases classified as subacute and acute; between chronic and subacute; from acute to hyperpyrexia. They are varying degrees of the same chemical disorder, alternating, blending indiscernibly.

Cases in which hyperpyrexia supervenes, are identical with the usual acute cases, at the outset.

Neglected, acute rheumatism may evidence no

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moderation for weeks; yet after four or six weeks of unrelinquished severity, it is as amenable to enlightened treatment as it would have been on the first day. With the application of unchanging chemical laws at any time in its course, counteraction is at once prompt and complete. Decisive, irrefragable attestation of chemical etiology.

Uncomplicated rheumatism, irrespective of duration or severity, never ends in suppuration. This extraordinary feature is likewise explained by the chemical nature of the complaint. Numerous recrudescences at varying intervals for years, constituting a part of the life history of the patient, can be solved only by recognizing its issuing from disordered metabolism.

Deficiency of basic constituents and of vegetable acids in food; excess of animal proteid, particularly nuclein; imperfect oxidation; defective elimination, are etiological factors of rheumatism.

Alcohol is a potent factor, by its action on the liver, where much important metabolism takes place; by interference with oxidation; by causing retention of poisonous waste products in all tissues and fluids of the body. The effect of alcohol is irremediable by any management, the cause abiding. Seldom does a patient keep faith with his physician regarding this important factor.

Foods rich in basic constituents and vegetable acids, organically combined with vegetable proteid, with a minimum of animal proteid; proper oxidation and elimination, cure and prevent rheumatism.

An alkaline base in organic combination, is stored with the proteid with which it is absorbed and assimilated, only to be excreted after metabolic decomposition, thus ensuring the presence of these bases at the spot where acids of metabolism are set free. If absent or deficient, the acids satisfy their chemical affinity by union with those bases which are constituents of living tissue.

Mineral water, drugs, alkaline solutions, may render the urine neutral or alkaline, without in the least influencing or neutralizing tissue fluids-they never reach them, therefore they never cure-only relieve acute phenomena.

For healthful metabolism, and neutralization of acid-products, there must be definite, constant proportions of potassium and sodium compounds.

To reach the tissues and tissue fluids, they must be in organic combination as produced by nature. Potassium is chiefly taken in with food; sodium compounds are largely formed by oxidation of vegetable acids. Vegetable food contains three to four times as much potassium as animal food. Cereals, potatoes, bread, all important vegetable articles of diet, are rich in potassium, and are essentials of the diet with rheumatic predisposition.* Salts of vegetable acids, by oxidation in the body, form alkalicarbonates. Vegetable acids, therefore, are equally

*It is most essential that potatoes, however served, should be cooked in their jackets; for the reason that the outer rind, just under the thin skin, is the richest in potash, and constitutes a chief supply of these salts to the body. This portion is sacrificed in peeling. As far as practicable, vegetables should be steamed instead of boiled, as boiling dissolves out the potash salts. Fruit should be eaten raw. When cooked the chemical union of salts of vegetable acids is destroyed.