junctival discoloration went through the usual changes after any blood-clot. The patient made a good re

covery.

Operation in Spinal-cord Injuries. The advantages. of surgical intervention in this class of injuries are thus enumerated by P. J. Mixter, and H. M. Chace who report two cases: (1) Operation removes depressed fragments of bone apparently lying against the cord; (2) It removes blood-clots; (3) Allows the escape of exudate and makes room for inflammatory thickening; (4) If extensive hemorrhage is present, either extral or intradural, it relieves pressure from the cord. Cases in literature have shown that degeneration from pressure appears within four days; if a cord is injured by crush and not totally destroyed, the continued pressure of a bloodclot may succeed in completing total destruction. (5) Traumatic spinal oedema may be of such extent as to demand greater space for enlargement of the cord to avoid further destruction of fibers; (6) There is absolutely no method by which one can early diagnosticate slight or great pressure of a fragment of bone, the pressure of a small or a large hæmatoma, whether there is a momentary pinch of the cord or constant pressure; (7) The fact that the cord looked normal in the two cases reported does not preclude the possibility that pressure had existed, nor prove that a condition had existed in which drainage and relief of pressure were not distinctly beneficial; (8) The patients do not suffer from any ill effect of the operation per se, the dangers of operation are very slight compared to the possible benefit to be derived therefrom; and the further satisfaction is obtained that the surgeon knows that continued pressure does not exist.

The American Journal of the Medical Sciences, May, 1904. Experimental Studies of the Etiology of Acute Pneumonitis.-Augustus Wadsworth has been able to determine by means of an accurately controlled series of experiments which allowed of precise comparison, the effect of increasing or diminishing the virulence of the incitant, the pneumococcus, in systemically predisposed, in locally predisposed, and in both systemically and locally predisposed animals. These experiments, the writer declares, show that the excitement of diffuse lesions in the normal rabbit is extremely uncertain, and only possible in the predisposed rabbit when both the general and local susceptibility are increased and when organisms of comparatively low virulence are used. Thus, and owing chiefly to the fact that the lung surface acts as a barrier to infection, the development of acute exudative pneumonitis offers an especially clear example of the nice balancing of the essential condition determining infection. These conditions are, on the one hand, the specialization or virulence of the incident, and, on the other hand, the animal susceptibility, both local and systematic. Organisms of low virulence induce evanescent bronchial reactions; more virulent organisms, by a local infection, give rise to the more typical bronchopneumonic lesions; while organisms of still greater virulence, if confined to the lung, incite diffuse processes of the lobar type, but if not so confined and bacteriæmic infection occurs, the lung lesions are less marked and of the bronchopneumonic type. The extremely fine balance of these conditions essential to the formation of lobar lesions in normal as well as in predisposed animals is as yet, for practical purposes, beyond experimental control. The writer states, finally, that as a result of these systematic researches on normal and predisposed animals an entirely new procedure was adopted; the preliminary immunization of the rabbits so that extremely virulent cultures of pneumococci can be used without giving rise to bacteræmic infection. The experiments with this procedure showed that diffuse exudative lesions comparable to the lobar pneumonia of man may be incited experimentally in the immunized rabbit; and that in securing this result there are but two chief variable factors. The virulence of the incitant and the immunization of the animal; both easily and accurately controlled by the routine technique of the modern laboratory.

Nasal Syphilitic Tumors.-Max Toeplitz declares that the tertiary manifestations of syphilis, in the nose the most frequent, are often seen very early. The anatomical lesion is a gummous infiltration of the mucous membrane, independent affection of cartilage, periosteum, and bone, and simple infiltration, with softening, ulceration, either from without, inward, or inversely. The favorite seat of the infiltration is the septum. The tumors are either extremely large gummata or so-called granulomata. The writer gives an account of several patients afflicted with these growths. These tumors obstruct the nose when large enough and discharge fibrinous, smeary, and purulent secretions. They cause pain in the head, face,

shoulder, and paralytic weakness in the arm. They are of variable size and are implanted upon the mucous membrane with a broad or pedunculated base. They are red, reddish gray, not quite smooth, and show frequent erosions but rarely ulcerations. The tissue is boggy, brittle, still without tendency to decay, its main distinction from gumma. Many histories could be related in which the microscopical examinations revealed apparently a sarcoma which disappeared under anti-syphilitic treatment. The diagnosis of these tumors is difficult if the patients do not show other syphilitic signs and the history does not furnish any support. The new formations are true tumors, pure connective tissue growths originating from the submucous connective tissue. The giant cells, which resemble the tuberculous giant cells of Langhans, are proliferations of endothelia from the walls of small veins and the leucocytes also take part in their production. The fibrous connective-tissue stroma is the distinguishing feature between these tumors and a round-celled and spindle-celled sarcoma, in which the fundamental substance in sparse and more homogeneous or slightly granular. In one case described, the tumor consisted of cellular tissue of moderate vascularity, mostly round cells and young connective-tissue cells. Besides it contained a large number of partly rounded, partly elongated giant cells, with numerous processes and marginal nuclei, and at some places firmer tracts of connective tissue. clinical proofs are the history and other syphilitic lesions. The best criterion for the diagnosis is the success of the anti-syphilitic treatment.

The

Distribution of the Ulcers in Typhoid Fever.-Joseph Louis Baer gives a review and discussion of the literature on this subject and an analysis of his series of eighty-nine cases. After presenting statistics, the writer states that several facts worth noting are brought into prominence. Probably the most striking among these is the wide distribution of the typhoid ulcers. They are found in every division of the alimentary tract excepting the mouth, and they are found also in the larynx and trachea. Gastric ulceration, though very unusual, is now regarded as quite possible in typhoid fever. The duodenum is the second rarest site for typhoid ulcers, only three cases being found. The low percentage of ulcers in the jejunum, 5% per cent., calculated from a total of 1,358 cases, confirms the general impression as to the infrequency of jejunal involvement. Involvement of the ileum is found in 89 per cent. of the cases. Ulceration of the small intestine in any part has been recorded in 97.5 per cent. of 623 cases. Ulceration of the common bile-duct is the rarest site for typhoid ulcers. One case is reported in a series of 439 cases. Involvement of the large intestine alone was not found in any statistics of the literature. In the present series, however, 5 cases were found. The one important factor in determining the seat of the lesions is the extent and character of the lymphatic apparatus of the part. Yet the frequent occurrence of pharyngeal and laryngeal involvement, indicate that accidental lodgement of the typhoid bacilli is another factor of considerable importance. The fact that there are many cases of typhoid fever without ulceration points to the existence of other possible factors, such as a lowered resistance of the gastrointestinal mucosa, which in these cases without ulcerations has reached its lowest ebb.

On the Surgical Importance of the Visceral Crises in the Erythema Group of Skin Diseases.-William Osler states that the possibility of mistaking these visceral crises for appendicitis or intussusception, or obstruction of the bowel and handing the patient over to the surgeon for operation, is by no means remote. The writer gives a short history of three cases in which laparotomy was performed and draws from them the following practical lessons: First, in children with colic, the greatest care should be taken to get a full history, which may bring out the fact of previous attacks, either of skin lesions, of arthritis, or of intestinal crises; secondly, there should be made the most careful inspection of the skin for angioneurotic oedema, purpura, or erythema. It should also be remembered that recurring colic may be for many years the sole feature of this remarkable disease; and the obscurity of the attacks of colic may not be cleared up till the final appearance of skin lesions. In one of the cases here reported, the intestinal crises, in combination with arthritis and the renal features, leave no doubt as to the diagnosis, The writer says that in the next attack there may be purpura or angioneurotic oedema, or an acute nephritis may occur alone. The colic is the most constant of the visceral manifestations, occurring in twenty-five of the It seems never twenty-nine cases in the author's series.

to be dangerous. In no case recorded has death resulted from intestinal causes, according to the writer's belief.

Society Reports.

ASSOCIATION OF AMERICAN PHYSICIANS. Nineteenth Annual Meeting, Held in Washington, D. C., May 10 and 11, 1904.

Dr. WM. T. COUNCILMAN OF BOSTON, IN THE CHAIR. TUESDAY, MAY 10-FIRST DAY.

The President's Address.-Dr. COUNCILMAN, after welcoming those present, advocated the removal of limitation of membership, and also asked that membership in the association be limited to twenty years after which they would be placed as honorary members. In this manner at least seven new members could be acquired each year.

The Influence of Suprarenal Extract upon Absorption and Elimination with Demonstrations.-Dr. S. J. MELTZER and Dr. JOHN AUER of New York presented this communication. A description of experiments to establish the retarding effect of suprarenal extract upon absorption and elimination was made by Dr. Meltzer. When adrenalin was given to frogs they rapidly became paralyzed, and this effect was not a muscular paralysis, for it could be demonstrated that stimulation of the sciatic nerve resulted in muscular contraction as occurred in normal muscles. The paralytic effect, therefore, was a central

one.

This same effect was shown in rabbits. If .6 mg. of strychnine was injected there followed a fatal effect of tetanic nature in from fifteen to twenty minutes; but if adrenalin was first injected there would be no tetanic effect at all, and this was explained by the delayed absorption. Further studies were made with some substance which was harmless to the animal, as fluorescin; this was injected subcutaneously into a rabbit, and after a few minutes the conjunctiva became yellow, the mucous membranes, the urine and the skin. When adrenalin was given it appeared considerably later, showing again delayed absorption. It was also proven experimentally that not only was absorption delayed, but also elimination.

Polyuria in Typhoid Fever.-Drs. M. H. FuSSEL, H. S. CARMANY, and H. HUDSON of Philadelphia presented a paper on this subject. A man, forty years old, was admitted to the hospital on the eighth day of his fever, April 15. The temperature ran the ordinary course. On May 7 it became and remained normal until his discharge. He was an extremely nervous individual. April 23 he had a slight intestinal hemorrhage. When he entered the hospital he had been getting 5 grains of salol every three hours, which gave rise to the presence of salicylic acid in his urine. He was bathed, but not tubbed, and was given eleven baths. The first twenty-four hours after his admission he passed 1200 c.c. of urine; the second, 1,500 c.c.; the third, 7,000 c.c.; the fourth, 7,200 c.c., and then it dropped to 3,500 c.c., where it remained for some time. The polyuria really was a complication of the disease because it disturbed him so much. The skin was dry, and he was very restless. One year after this attack he was examined again, and the urine was found to be normal.

Polyuria in Typhoid Fever.-By Dr. JAMES C. WILSON of Philadelphia (read by title.)

Dr. GEORGE Dock of Ann Arbor, Mich., said that the elimination of water in typhoid fever in the beginning was but little, there being actually a retention of fluid within the body; soon after the amount of fluid excreted was increased, until at last there was a polyuria; observations he had made confirmed this. He thought that a later diminution in the excretion of the urine could be explained by the weakening of the heart's action and a lowering of the blood pressure.

Dr. WILLIAM OSLER of Baltimore said that polyuria that occurred in tuberculous peritonitis, in retroperitoneal tumors, in aneurysm of the abdominal aorta, etc., might be the result of local irritation.

Dr. FUSSELL, in closing the discussion, said that the

more water that was discharged the less hysterical the patient seemed to be.

Cases of Venous Thrombosis Occurring in the Course of Typhoid Fever.-Dr. W. S. THAYER of Baltimore read this paper. He said that his observations were taken in Dr. Osler's wards at the John Hopkins' Hospital, and out of 1,462 cases of typhoid fever there were 39 instances of venous thrombosis, or 2.6 per cent. In 5 of these 39 cases a fatal result was recorded. The lower extremity was the seat of the thrombosis in all but a very few of the cases. In 21 instances the thrombosis was in the femoral vein, popliteal vein in 5, iliac vein in 5, in the calves of the leg 5, in the saphenus vein 3, etc. In 36 cases the development of the condition was associated with fever; in 3 there was none. In 26 cases the fever was intercurrent; in 13 the temperature was normal at the time the thrombosis was first noticed. In 11 of the 39 cases the complication was associated with chill. The first distinct symp tom was pain, and, in the instances of femoral thrombosis the pain was along the course of this vein. In 22 of the cases a leucocytic count was made, the highest recorded being 24,864; this was in a case of iliac vein thrombosis occurring during the third week of the disease. The lowest was 2,700, and this occurred on the day after the onset of the thrombosis. In all of the instances there was more or less prolonged disability. In 6 cases there was oedema lasting several weeks and longer; in 4 there was severe cramps in the legs; in 1 the patient complained of severe pain in the leg and thigh, especially after standing. The following brief conclusions were drawn; In 28.2 per cent. of the cases the venous thrombosis was associated with chills, and, in most of the cases, there was an increase in the leucocytic count, depending upon the extent of the lesion. In cases of sudden severe pain in the lower part of the abdomen and associated with leucocytosis the possibility of iliac thrombosis should be carefully considered. He emphasized the fact that thrombosis of the veins of the lower extremity was a very serious condition, and the after-results should not be lost sight of. Marked varicosities may be present and lead to more or less permanent disability, as illustrated in a photograph he showed.

Dr. GEORGE L. PEABODY of New York referred to the + giving of calcium salts to increase the coagulability of the blood. This coagulability of the blood could be diminished and the likelihood of thrombosis lessened by administering citric acid which reduces the solubility of these salts.

Dr. ALFRED STENGEL of Philadelphia said that at times the general symptoms preceded the local signs. He referred to one case; this patient entered the hospital in the convalescent period with a marked septic fever, temperature reaching 106 or 107°, decided chills and sweating, without there being any local symptoms whatever. The leucocyte count was 7,000. The general appearance of the patient, the emaciation, the absence of leucocytosis lead to the tentative diagnosis of posttyphoidal thrombosis.

Dr. WILLIAM H. WELCH of Baltimore said that the French school favored the old view that these cases were of primary origin due to infection of the venous walls and subsequently a phlebitis. Importance was also placed upon the increased pulse rate as an important sign.

Dr. W. GILMAN THOMPSON of New York said he had under observation eight cases of femoral thrombosis, all these patients having suffered from general weakness and oedema for from six to ten years.

Dr. JAMES TYSON of Philadelphia ascribed the pain accompanying thrombosis to vascular obstruction, such as occurred in angina pectoris and in cramps in the calves, etc.

Dr. WILLIAM OSLER of Baltimore spoke of the difference between phlegmasia dolens after puerperal fever and the thrombosis of typhoid fever. In the latter, one might

say, it gave the typical picture of post-partum phlebitis, with the swelling, the white color, the pain which may or may not be localized but not extremely agonizing, as in post-puerperal cases. He did not believe these cases were quite as severe as ordinarily stated. He had known of several cases in which recovery was complete and the circulation established. He believed that the patients with femoral thrombosis should blame their parents because the thrombosis depended upon the venous arrangement: if a man was well put together and had a well-arranged venous circulation, he could have a femoral thrombosis and yet recover with a good circulation.

Clinical Studies in Arteriosclerosis.-Dr. ALFRED STENGEL of Philadelphia read this paper. He considered the blood-pressure conditions in both the early and in the later stages of arteriosclerosis. The blood pressure was ascertained by means of an instrument devised by Dr. Stanton, and was of value in that it recorded both the diastolic as well as the systolic pressure. Systolic pressure in arteriosclerosis was not necessarily high, but the diastolic blood pressure was always high until that time when the myocardium was diseased and failed. Therefore, the diastolic blood pressure was the most imporant factor to determine in this disease. Sustained pressure was, of course, more characteristic. He next spoke of the blood changes, contrasting them with the appearance of the patient. He said that all knew the arteriosclerosis facies, the pallor, etc., which appeared rather rapidly. He had seen cases with such changes that made him suspect malignant disease. In examining the blood of these people one always finds unexpectedly a high blood count. Whether this was due to inspissation of the blood or to the same cause that was effective in producing European tropical anæmia, was a question he could not answer, although he favored the latter view. The condition of the urine showed a great variability in the amount excreted and in the specific gravity. Sustained systolic blood pressure and sustained first heat sound were considered. He said that one of the first evidences of cardiac sclerosis was a sustained and prolonged character of the first heat sound before the myocardial degeneration appeared, and this was a very important point in determining the early development of arteriosclerosis.

Dr. S. SOLIS COHEN of Philadelphia said that many factors were involved in the estimation of the blood pressure in these cases. In his own clinical observations he said he was inclined to lay great stress upon the prolongation and impurity of the first sound. Regarding the condition of the urine, he had not only found changes in the specific gravity but also in the toxic content.

An Investigation of the Effects of Cardiac Stimulants, Especially Strychnine, on the Blood Pressure in Febrile Conditions.-Dr. R. C. CABOT of Boston considered this subject and gave the measurements of the maximum and minimum blood pressure made with the Stanton modification of the Riva Rocci instrument in febrile cases before, during, and after the administration of strychnine both by mouth and subcutaneously. Among these cases were 31 of typhoid fever, 4 of pneumonia, and 15 with a variety of diagnoses. Over 5,000 measurements were taken and the total results were negative. One-eighth to one-sixth of a grain of strychnine were given, careful records were taken, and all with negative results. The emotions caused by the sight of a friend, by the sight of food, etc., caused as great an increase in the blood pressure as did the drug.

Dr. ALFRED STENGEL of Philadelphia said that the results obtained by Dr. CABOT substantiated the views of the French school, that this increase in the blood pressure was a vasomotor disturbance; this was shown by the increase in it through certain emotions.

Dr. HOBART A. HARE of Philadelphia said that strychnine was not a cardiac stimulant, although the profession in general used it as such, as they used to give digitalis. All must be convinced that the drug was much abused

in typhoid fever, in pneumonia, and in diseases in which stimulation was greatly desired. Strychnine did not act in the sense that it increased the force of the circulation; he thought it acted simply as an irritant and produced its effect upon the nervous system akin to whipping a horse.

A Supposed Cause of High Tension Pulse in Nephritis.— Dr. Wм. H. THOMSON of New York read this paper, in which he stated that a high tension pulse occurred too early in nephritis to be due to any other cause than the presence in the blood of a general vasoconstricting agent similar in its properties to adrenalin, and that such an agent would also produce constriction of the renal vessels and general shrinkage of the kidneys, causing interference with the excretion of urea. Prolonged presence of such an agent in the blood would lead ultimately to endocarditis with degeneration of the vascular walls and to cardiac changes. Acute cardiac dilatation may occur from the effects of such a general vasoconstricting agent in the circulation before extensive alterations in the blood-vessels had taken place. Aconite he considered to be the best vasodilator in nephritis, much more effective than the nitrites. Reports of marked increase in the excretion of urea followed its administration.

Dr. GEORGE L. PEABODY said that his own experience showed that there was no doubt regarding the effects of aconite, even when there was an abnormally low-tension pulse, to frequently increase the urea output.

Poisoning by Illuminating Gas-A Clinical Study of Ninety Cases.-Dr. W. GILMAN THOMPSON of New York read this paper. After referring to the comparatively few cases recorded in the literature, he summarized as follows:

1. Leucocytosis was both high and persistent, rising. in many cases above 18,000 and, in a few fatal cases, as high as 50,000. A differential leucocytic count showed a preponderance of the polymorphonuclear cells. A high degree of leucocytosis was a very unfavorable sign.

2. The elevation of temperature was observed in nearly all the cases. The fever was usually moderate and of very irregular type. In many cases a subnormal temperature preceded the elevation, and it was often observed also in convalescence. The pulse was disproportionately rapid as compared with the temperature.

3. The nervous symptoms were both varied and inconstant. Convulsions occurred in about 7 per cent. of all cases and muscular rigidity in a slightly larger proportion. The reflex and pupil symptoms showed great variability. The coma bore no definite relation to the intensity or duration of the fever. Coma lasting four or five days was not invariably fatal. In the series of ninety comatose cases only 17 or 18 per cent. were fatal.

4. The result of combined phlebotomy and saline infusion justified this prompt and thorough employment of these

measures.

5. Pneumonia was an infrequent complication, and, in a large percentage of fatal cases, the cause of death could be referred to cerebral lesions, such as congestion of the meninges and brain substance, hemorrhage of the cerebral capillaries, or hemorrhage into and softening of the internal capsule, lenticular nucleus and adjacent structures.

Dr. ALFRED STENGEL of Philadelphia said that a few years ago Darrah made a series of experiments in resuscitating animals poisoned by illuminating gas, and he found that they could not be brought to and saved by saline transfusions. The combination between the gas and the hæmoglobin was so close and the attempted disassociation so slow that the animals died before the poison was eliminated.

Dr. GEORGE L. PEABODY of New York said that defibrinated blood for use in such cases was logically all right, but was very difficult to get when needed. The use of oxygen in these cases he considered to be absolutely useless. He referred to one case in which the coma existed for four weeks with recovery of the patient.

Dr. FRANCIS P. KINNICUTT of New York said that neither the depth nor the length of the coma should be taken as indications upon which to base the prognosis. He spoke of the phenomenon of seeing cases of illuminating gas poisoning with beautiful ruddy red color.

Dr. HOBART A. HARE said that oxygen to be effective in these cases should be administered pure as possible. Regarding defibrinated blood, not only was it difficult to obtain when needed, but also it was an objection to introduce the blood of one man into the circulation of another.

Dr. S. SOLIS COHEN of Philadelphia said that there were other gases besides carbon monoxid to consider when speaking of illuminating gas which varied both in quantity and in kind and belonged to the hydrocarbon series. Before the adjournment of the morning session Dr. S. WEIR MITCHELL read a communication from Noguchi, who was in Copenhagen carrying on experiments with snake venom. This Japanese was associated with Dr. Mitchell and Dr. Flexner, and drew attention to himself by his good and able work. The attention of the Carnegie Institute was called to him, and he received from it enough money to enable him to go abroad to continue his work in the line of investigation. This fostering of scientific research, when effective and good men were found, was much encouraged, and this letter from Noguchi was loudly applauded.

Abdominal Pain from Unsuspected Irritation of the Internal Inguinal Ring.—Dr. CHARLES G. STOCKTON of Buffalo presented this communication, and reported twelve cases in which abdominal pain occurred as the result of irritation at the inte nal inguinal ring, dependent upon very slight protrusion of the hernial sac into the inguinal ring. The cases were believed not to be uncommon, and were sometimes perplexing and often misinterpreted. As a rule the pain followed exercising, but in one case it appeared when the patient was at rest. Such cases should be understood, otherwise they may be taken for cases of appendicitis and other visceral troubles. These cases could be relieved by proper support by truss.

Dr. GEORGE L. PEABODY of New York related the case of a physician who had attacks of severe pain in the lower half of his abdomen which was intermittent in character. He was found to have a patulous inguinal ring and the application of a well-fitting truss relieved him.

Dr. GEORGE DOCK of Ann Arbor related a case illustrating the fact that at times pain in the abdominal region may be felt far away from the seat of the disease. The Mechanism of Exophthalmos.-Dr. W. G. MACCALLUM and Dr. W. B. CORNELL of Baltimore presented this paper. The question existed as to the mechanism by which the exophthalmos which appeared in the dog on stimulation of the cervical sympathetic was produced. Certain authors held it to be due to distension of bloodvessels in the orbit, others to contractions of smooth muscle fibers about the eyes. Experiments showed that obstruction to the outflow of blood caused only an insignificant protrusion, and that the results of sympathetic stimulation were independent of any connection of the head with the circulatory apparatus. Direct observation showed that the exophthalmos was produced by the peristaltic contraction of a cone of tissue containing smooth muscle fibers which surround the eyes.

Diabetes Insipidus.-Dr. THOMAS B. FUTCHER of Baltimore took up the consideration of this subject and said that in seven out of nine cases observed in the wards of the John Hopkins Hospital were on the medical side and represented .03 per cent. of all cases therein. The cases he divided into two groups, (1) the primary or idiopathic, and (2) the secondary or symptomatic. The disease was more common in young individuals, the majority being between the ages of twenty and thirty years. Heredity was an important causative factor. It was more prevalent among males. Lesions of the brain seem to produce the disease in the majority of the cases. Diabetes insipidus may follow hemorrhage, hydrocephalus, basilar meningitis,

or tumors at the base of the brain. Four out of the nine cases were due to lues, and polyuria and polydypsia were, symptoms, too, of cerebral syphilis. Syphilis as an etiological factor in diabetes insipidus was emphasized.

Dr. BAUMGARTEN of St. Louis reported a case of polyuria lasting for nine months when sugar then was first found. This patient died of tuberculosis of the lungs. Dr. JAMES TYSON of Philadelphia said that he had been called in consultation to see as many as six or seven cases of diabetes insipidus, and the most interesting feature was that they were all largely relieved by the administration of iodide of potassium. He never knew of a case in which the patient died, although two or three that seemed to have recovered passed from observation.

Dr. GEORGE Dock of Ann Arbor spoke of the cheery prognosis that could be given these cases with a syphilitic history.

Dr. A. JACOBI of New York said that the large majority of such cases were found in young children, and, as a rule, were not seen in the general hospitals. He had seen a number of cases in which the cause appeared to be the result of an anæmia, or chorea, or following attacks of chorea minor. He had also seen it follow whooping-cough in which it was attributed to cerebral hemorrhages. He had seen it result as the direct result of falls upon the occiput in boys from seven or eight to thirteen years old. In these cases, too, it might be dependent upon tumors. A Case of Prolonged Male Hysteria with Autopsy.Dr. S. WEIR MITCHELL of Philadelphia gave a full report of a case of hysteria occurring in a man which lasted some thirty years, followed by a post-mortem examination which gave only negative results.

Dr. PRINCE of Boston reported an analogous case.

Some Unusual Forms of Acute Myelitis.-Dr. B. SACHS of New York read this paper. He said that in the discussion that had been carried on for years regarding acute myelitis, doubt had been expressed as to the occurrence of acute myelitis if all cases due to syphilis, to traumatism, and to infection were excluded. There was no doubt, however, that there were some other forms which could not be conveniently described under any other term. Special account was taken in his paper of a senile form which would appear to be a spinal counterpart of the cerebral apoplexies occurring during the senile period. The tissue changes in this case could be attributed only to disease of the spinal blood-vessel. The paper also included the record of a very sudden development of myelitis in a young girl who, shortly after the onset of the myelitic symptoms, developed multiple streptococcic abscesses. The case was very remarkable because of the severity of the symptoms and on account of the partial recovery that had taken place. The first abscess appeared in the gluteal region and spinal caries was first thought of. Within twenty-four hours multiple abscesses developed all over the body, and they developed almost simultaneously with the myelitis. She was now a chronic paraplegic.

Infectious Neuritis with Report of a Case.-Dr. Jas. J. PUTNAM of Boston reported cases he had seen in consultation and at the Massachusetts General Hospital. One case was thirty years old and resulted fatally after eight weeks' duration. Sensory and motor symptoms were present, there was a constant fever and a leucocytosis of 33,000. The paralysis progressed slowly and went upward until it involved the bulbar area. Post mortem showed in general a disintegrated condition without vascular changes. In another case the paralysis spread in somewhat a similar manner. The face became involved and swallowing became very difficult. Fever was constant. The spleen was not enlarged. This case ended in recovery and was believed to be a case of multiple neuritis.

The Clinical Features, Prognosis, and Treatment of Cerebrospinal Meningitis in Infants and Children.-Dr. HENRY KOPLIK of New York read this paper. The ma

terial collected in five years' hospital service numbered 89 cases of meningitis as follows: Forty-nine cerebrospinal, 39 absolutely confirmed by puncture, 35 tuberculous cases, I staphylocococci, I streptococci, I pneumococci, and 2 were the so-called pseudo-influenza cases. Sixty per cent. of the cases were below the age of 2 years, the youngest being 4 weeks, the oldest 14 years. The average age among the tuberculous cases was about 4 years. He said the type cases in New York were the same as those of Councilman, Osler, Hirsch, Herrick of Chicago, and others. In one case the meningococcus was found in the conjunctival secretion. The clinical types were malignant, acute and subacute and basic. The mode of onset was sudden, as a rule, except in the tuberculous. Neck rigidity was always present at some period of the disease. The reflexes, if present at the beginning, may disappear toward the close. Babinski's reflex was present in 17 cases of cerebrospinal and 26 of the tuberculous, about 77 per cent. Kernig's reflex was of little utility below the age of 2 years. Myotonica congenita was present in all such cases. In the cerebrospinal cases hyperesthesia was present in 62 per cent. Macewen's sign, in the 17 tuberculous cases it was present in 11; in the cerebrospinal it was present in 2. The temperature was of the prevailing type. The skin showed the rashes of some sort always present, but not so much so as in adults. Herpes labialis infrequently was found. Conjunctivitis was common. Optic neuritis was very uncommon. The disk changes were common in the tuberculous type, about 77 per cent. Of 20 cases 7 showed tuberculous choroiditis. In the cerebrospinal form the leucocytes were from 20,000 to 55,000, exceeding 25,000 in 55 per cent. of cases. In the tuberculous cases 40 per cent. ran from 20,000 to 25,000. They were under 20,000 in 60 per cent. of the cases. Regarding the mortality, of the 49 cerebrospinal cases the death rate was 36.7 per cent.; of the absolute cases, 41 per cent. The disease he believed to be self-limited and not influenced by any mode of treatment. The varying mortality was about 62 per cent. and 25 per cent. Lysol injection treatment, 31 cases, 18 recovered, or 42 per cent., but this treatment did not prevent relapses. In his own cases lumbar puncture was not curative, nor did it prevent relapse or rise of temperature, nor did it relieve the headache and symptoms of pressure.

Esophagus

A Case of Spasmodic Stricture of the with Sacculation, Treated by Dilatation, and Later by Gastrostomy.-Dr. JAMES TYSON, Dr. EDWARD MARTIN, and Dr. THOS. EVANS of Philadelphia presented this communication. The patient was a man, thirty-three years old, who had suffered from dysphagia since he was twelve years old. At that time he was suddenly seized with dysphagia while eating his supper and regurgitated his food. For fifteen years he fed himself with great difficulty, taking solid food first and following it with large quantities of liquid. He was first examined by Dr. Tyson in 1895, and on attempting to pass a tube it bent upon itself when at the seat of obstruction. When the œsophagus was washed out a large quantity of mucus was obtained. The absorption and motor power of the stomach was good. He saw the patient again in 1903 when the condition was about the same. A floating kidney was then noticed and a slight gastroptosis.

A second case was reported in which the patient had been under observation two and a half years. The patient was a woman, thirty-three years old, with good family history and no tendency to neurotic conditions. Not much benefit being obtained from ordinary treatment, Dr. Martin saw her in consultation and advised dilatation and paralysis of the cardiac orifice by an apparatus of his own device. Dr. Martin thought he would have succeeded in this treatment had it been persisted in. Later a gastrostomy was done and the patient died soon after.

Idiopathic Dilatation of the Esophagus; Cardiospasm.Dr. B. W. SIPPY of Chicago presented an anatomical

specimen which was rare. The patient from whom it was taken was a woman, thirty-three years old, who gave symptoms of oesophageal obstruction for five years. She often would have to leave the table to regurgitate what she had eaten. The globus hystericus was present. Lost a great deal of weight, and symptoms soon became aggravated. In the hospital it was decided that she was suffering from pyloric obstruction and a gastroenterostomy was performed. This was followed by some betterment of her condition for one week when she returned to her old condition and she finally died. The oesophagus normally would contain 100 c.c. of fluid, but the one removed contained 500 c.c. There was a fusiform dilatation and an enormous hypertrophy of the walls of the œsophagus, especially at the point where dilatation was the greatest.

Dilatation of the Esophagus and Stomach.—Dr. FRANCIS P. KINNICUTT of New York presented this enormously dilated oesophagus which was a record breaker, so far as he could learn, in that it contained 1,800 c.c. of fluid.

WEDNESDAY, MAY II-SECOND DAY.

In

The Relation of Cells with Eosinophile Granulation to Bacterial Infection.-Dr. E. L. OPIE of Baltimore read this paper. The guinea-pig was the most suitable animal for the experiments made. Bacteria causing fatal affections, he said, gradually diminished the eosinophiles, and charts were shown to illustrate the effects of various bacteria upon eosinophile cells. The appearance of the eosinophiles in the tissues was in harmony with their disappearance from the blood. The influence of these and their severity in fatal affections suggested to him the desirability of studying their behavior during the course of acute affections from which animals were capable of recovering, and, in making the tests, the peritoneal cavity was believed to be the best because the fluids could so readily be obtained therefrom. During the course of pneumonia, typhoid fever, various pyogenic and other infections, eosinophile leucocytes disappeared in part or wholly from the peripheral circulation. jections of a variety of bacteria into the peritoneum of guinea-pigs caused a similar disappearance of these cells, followed after a few days, should the animal survive, by an increase above the normal. Examination of the mesentery during the height of infection demonstrated that eosinophile leucocytes collected in its blood-vessels, and hence migrated into the peritoneal cavity in company with the more numerous finely granular leucocyte. Eosinophile leucocytes, he said, collected in considerable number upon the surface of the omentum and here underwent degenerative changes. That eosinophile cells were profoundly affected by bacterial poisons was further shown by the accumulation of eosinophile myelocytes in large number in the spleen only four hours after inoculation. Eosinophile leucocytes had a part in the inflammatory process which followed bacterial invasion. He said that they rarely acted as phagocytes, but that they really did have a part in the bacterial invasion.

Dr. Opie said that there really was a contrast between animal parasites and bacteria, and a very marked similarity. Trichinosis caused a leucocytosis which was in part due to the increase in the eosinophile cells and in part to an increase in the ordinary polynuclear or neutrophiles. The first effect of bacteria caused a diminution in the eosinophile cells, but, as shown by certain studies, there was subsequently an increase in them if time was given for them to increase. Therefore, increase in the eosinophiles occurred with bacterial invasion when recovery occurred. It seemed to him that the toxins of the animal parasite and the bacterial toxins were chemotaxic for both forms of parasites.

A New Case of Chloroma with Leukæmia, with a Study of the Cases Reported Since 1893.-Dr. GEORGE DOCK and Dr. A. S. WARTHIN of Ann Arbor, Mich., presented this communication. Eleven years ago a condition was