on referring to the statistics of the last ten years that there has usually been a very marked increase in the annual number. These are the figures for the years from 1894 to 1903 inclusive, for Manhattan and the Bronx: 792, 965, 1,002, 1,004, 1,535, 1,290, 1,759, 1,915, 2,629, 2,642.

It is proper to state that during these years these figures also include the disease reported as typhomalarial fever, which can fairly be assumed to be really typhoid fever, I presume.

During these years the population also increased, of course, but not in proportion to the increase in the fever rate.

The following table shows the number of cases per ten thousand of population reported in Manhattan and Bronx from 1894 to 1903, inclusive, with the exception of 1901, for which year I have no record of the population:

The next column in the death-causes is malarial fever, to which were assigned, in 1903, 27 deaths in Manhattan, 36 in Brooklyn, and 90 in the entire city.

These numbers seem to me to be impossible, and they suggest inevitably errors in diagnosis on a large scale. They are not susceptible of any other explanation.

How many of us see deaths in ordinary times, due to malaria? Some may have occurred here during the Spanish war, and, years ago, during the period of the construction of the Panama railway we did occasionally see such a death; but at present I venture to believe that death from this cause in this city must be a great rarity.

Smallpox is the next disease to which a column is devoted. Our showing for 1903 in this regard is most satisfactory, namely, 43 cases reported and 5 deaths.

In connection with smallpox, forcible removal of the patient by the Health Department is of more than scientific interest.

It has long been my desire to ask for a discussion of this subject. There could be no better place for such a discussion than this society, which contains so many upon whom the Department depends for advice; and there could be no better time for it than the present, when smallpox is not prevailing.

If a patient can be suitably isolated in his home, so that neither he nor those in attendance upon him come in contact with those who are not protected by vaccination, the necessity for such a procedure is not apparent. The fact that it is still insisted upon in this city is naturally taken to indicate that vaccination is not considered to be protective here.

If such a practice were carried out with reference to almost any of the other infectious fevers it would be at least logically defensible, however it might be open to criticism from other points of view; but the selection by the Health Department of the only one of all the list of acute infections, which we all believe

to be absolutely preventable by the easy establishment of artificial immunity tends to bring obloquy on sanitary science, and seems harsh and arbitrary and, in some cases, cruel.

If reasonable isolation is not practicable in the patient's home the case becomes different, of course. I am now referring to cases in private houses, so situated as not to be in contact with any but the necessary doctors and other attendants, and when these attendants may be counted upon to abstain from contact with the unvaccinated, or, as in the case of the doctors, to reduce that contact to a minimum.

Suppose, for example, that a member of your own family should develop smallpox. It should amply satisfy all the requirements of hygiene if the upper part of the house were to be surrendered to the patient's uses, and if none but those protected by vaccination were allowed in the part of the house reserved for him, and if those in attendance upon him kept apart from the unvaccinated as far as practicable and adopted all the usual means to prevent the spread of the infection. All of this might properly enough be supervised by the Department as a condition of leaving the patient in his home under the circumstances, and it might be somewhat expensive, but probably no more so than the present method of dealing with the condition.

It is probably not far from the truth to suppose that many of us, under present circumstances, would deliberately conceal the existence of this disease in our own families and take the risk of consequences, punitive and other; and from this it is but a short step to believing that we would do the same thing for a relation or a friend.

There can be no doubt that dread of the enforcement of this regulation has led to concealment and flight, and thus to much greater exposure than would occur under circumstances that I am advocating.

Although exceptions to this rule of forcible removal are occasionally made in the other boroughs. no exception is ever made in Manhattan.

It is within the recollection of many of us that smallpox was treated in the general medical wards of the Paris hospitals; and in France, Germany, Austria, and England such patients were treated in their own homes some years ago when I had occasion to be familiar with the facts in those countries.

This was the case in these continental countries where no one family occupied an entire house, but where many families lived together under one roof and used the stairs and waterclosets in common.

Twenty years ago this was the practice here, it would be interesting to know what causes led to so radical a change of plan.

In England, Section 124 of the Poor Law Act* tells us that under some circumstances a patient may be removed by the authorities to a hospital, but the circumstances are very different from those that we are supposing. Let me quote to you the section of the Poor Law Act so far as it relates to this subject:

"Where any suitable hospital or place for the reception of the sick is provided within the district of a sanitary authority, or within a convenient distance from such district, any person who is suffering from any dangerous infectious disorder, and is without proper lodging or accommodation, or lodged in a room occupied by more than one family, or is on board any ship or vessel, may, on a certificate signed by a legally qualified medical practitioner, and with the consent of the superintending body of such hospital or place, be removed by the order of any *"Treatise on Hygiene," Stevens and Murphy, Vol. III, P. 164.

justice to such hospital or place at the cost of the sanitary authority; and any person so suffering who is lodged in any common lodging-house may, with the like consent and on a like certificate, be so removed by the order of the sanitary authority."

The possibility of removing patients as a consequence of erroneous diagnosis is a serious aspect of the case; and the unwillingness of practitioners to subject their diagnoses to official review, is in part based upon a fear of this possibility.

Some years ago I saw a case of pustular eruption due to local use of croton oil which had been sent to the Health Department and kept over night as a possible case of smallpox.

It has often happened to me to share the responsibility with another doctor of making the diagnosis between variola and varicella, and then to remind him of his duty to report the case to the Health Department. Very commonly he says that he prefers not to do so, lest the family should be needlessly alarmed if the case be one of varicella. More than once he has told me that even if I believed it to be variola he would not be willing to take any step which would tend to its forcible removal to the smallpox hospital.

This is probably not an unusual occurrence, and it is likely to be repeated as long as the present practice prevails; and thus the ends of hygiene and prophylaxis are likely to be defeated.

To revert for a moment to the possibilities and consequences of erroneous diagnoses. As high an authority as there is among us has told this society of the difficulty of making the differential diagnosis, and of its actual impossibility in some cases; and we all know that the father of modern dermatology maintained till his death that the two diseases were identical to the extent that either one might give origin to the other.

During the past winter a dermatologist of international reputation endeavored to persuade me that a case of varicella which occurred in the person of a doctor who was convalescing from a relapse of typhoid fever was one of smallpox, being misled by the height of the fever.

It is certainly possible for any of us to mistake the one for the other. I have known several physicians of large experience unable to distinguish between erythema multiforme and smallpox.

Moreover it is within the memory of most of us that a mistaken diagnosis led to grave public scandal and to a successful suit at law in which substantial damages were recovered from a reputable practitioner whose sole offense was that he had reported a doubtful case to the Health Department, and had thus become the unwilling cause of the patient's forcible removal, after diagnosis by one or more of the officers of the Department.

Thus the risk incurred by the practitioner in reporting a case that he believes to be smallpox is not trivial; and his temptation to conceal it becomes proportionately great.

We are all so proud of the work which our health department has done in the multifarious spheres of its activity in the prevention and cure of disease, that we must be forgiven if we appear to be unduly sensitive when it lays itself open to attack, as it seems to the writer to do in this instance.

The next subject in the list to which I shall ask your attention is diphtheria and croup. By croup I understand laryngeal diphtheria to be meant. Of 18,317 cases reported for the entire city the total mortality is 2,190, or between 11 and 12 per cent.

It seems very strange that hernia and intestinal obstruction together should be responsible for nearly 500 deaths a year in the entire city. To be exact, it is recorded at 485 for 1903, and at 490 for the previous year.

It is very shocking to note that there occurred 4,068 deaths by violence in the entire city. In this category Manhattan leads all the other boroughs with 2,355, and is followed by Brooklyn with 1,144. The risk of a violent death is nearly twice as great in Manhattan as in Brooklyn, allowance being made for the difference in population; but in both of these boroughs the death rate from this cause seems shamefully high. It does not take much experience in the streets of this city to teach one the barbarously low value that is placed on human life here, and the utter recklessness with which danger to life is disregarded.

This very instructive publication supplies much food for discussion, but I will not increase this evening the tax that has already been imposed upon your patience.

ment of antitoxin may reduce this death rate. A year earlier the mortality from this same cause was over 13 per cent.

insufficient attention has been paid. I do not mean to imply that the exact nature of the bone lesion is invariably determinable from a study of the

radiograph, but, together with a consideration of the clinical symptoms, the radiograph often furnishes corroborative evidence. Beyond this, and often in cases in which the diagnosis is shrouded in obscurity, a good radiograph, properly interpreted, will surprisingly often throw the weight of evidence one way or the other.

It is my desire here to set forth a few points of difference that are readily discernible in the radio

neoplasms and osteomyelitis, and for this purpose in treating of bone neoplasms, I am able to treat only of the two large groups of carcinoma and sarcoma without entering further into varieties, and in a general way to point out their radiographic char

acters.

The radiograph of carcinoma in bone shows an area of rarefaction which is circumscribed and rather sharply demarcated from neighboring bone. The area of carcinomatous rarefaction is homogeneous and does not give the mottled appearance to be detected in osteomyelitis. The area of rarefaction is medullary and not cortical. The size of the area of rarefaction is commensurate with the length of time of the clinical symptoms. The periosteum shows no evidence of new bone proliferation. The entire thickness of bone soon becomes involved in the process of rarefaction, and even spontaneous fracture occurs before there is much gross involvement of the other structures. Fig. 1 demonstrates these characters. The subject was a woman, thirty-eight years of age, suffering from carcinoma of the breast. The bone lesion is metastatic. The radiograph corresponds to four weeks' duration of local symptoms.

Of sarcoma of bone there seems to be two distinct groups from the radiographic standpoint. The one

FIG. 2. Tracing of radiograph of a myeloid or giant-cell sarcoma. graph and which seem to characterize, at least in a measure, certain types of bone disease, and with a large degree of probability suggest a difference between neoplastic and inflammatory processes.

The morbid processes that can enter into this differential discussion are limited. In this communication I have confined myself to a study of inflammatory and neoplastic conditions of bone.

A

In general, it is to be remembered that when periosteum becomes irritated its osteoplastic function becomes stimulated and new periosteal bone is formed upon its osteal surface. When periosteum becomes disturbed to the point of destruction or approaching that point, no such change occurs. good radiograph will present various phases of periosteal alteration in certain bone lesions, and I believe permit of deductions that throw light not only upon the kind of irritation but often also upon the period of time that irritant has been active. The information furnished by the radiographic picture of the bone itself seems also to be more or less distinctive in accordance with the lesion.

A hemorrhage into periosteum or between it and bone, will be recognizable or not in the radiograph according to the age of the lesion, that factor determining the extent of new periosteal bone formation. A subperiosteal collection of pus may present the identical picture, but this point the clinical symptoms must determine.

The aim of this article is, however, to bring out points in differentiation between osteoperiosteal

Unfortunately I am unable to furnish a radiograph of this type of tumor; such a radiograph is entirely characteristic of this group, and from it the diagnosis can be made with a great degree of certainty.

Spindle and round-celled osteosarcomata occurring in the length of long bones, present pictures different from the foregoing. These tumors usually cause a gradual fusiform dilatation of the shaft of the bone. In a good radiograph the medullary canal can perhaps be seen for the greater length of the bone, in which case it will be seen to widen out at the level of the growth. The periosteum can be seen very much thickened and of a different density than the soft tissues, but showing no proliferation of new bone. The bone itself is homogeneous, or at all events does not show the sudden transition of light and shade to be seen in radiographs of osteomyelitis (Fig. 3).

A study of the radiographs of osteomyelitis also shows features more or less distinctive. Osteomyelitis, accompanied by subacute or chronic symptoms, is the only variety that need be taken up in this relation.

The features characterizing osteomyelitis in the

caused by liquified areas and small areas of density where bone has become thickened. Cloaca and sequestra can sometimes be seen.

Periosteal involucrum will stand out prominently when present, or else the periosteum will show evidences of thickening and often of bone proliferation.

FIG. 5. Subacute osteomyelitis of ulna with thickened involucrum. The appearance of the periosteum will often suggest the length of time the disease has been in progress and furnish an important factor (in the clinical data (Figs. 4 and 5).

In the foregoing I do not wish to imply that the radiograph offers an infallible guide to a differential diagnosis of the several bone conditions discussed. If, however, the radiograph be properly interpreted, it will often cast a flood of light upon the pathological condition, even though other diagnostic methods fail utterly to disclose the true nature of the lesion.

18 EAST SIXTIETH STREET.

Medicopsychological Association. -The sixtieth annual meeting of this society (formerly known as the "Association of Medical Superintendents of American Institutions for the Insane") will be held at the Planters' Hotel, St. Louis, on May 30 and 31, and June 1, under the presidency of Dr. A. E. Macdonald of New York City. The secretary is Dr. C. B. Burr of Flint, Mich. The program announces the titles of twenty papers promised for the meeting.

VISITING PHYSICIAN TO BELLEVUE HOSPITAL, NEW YORK; PROFESSOR OF CLINICAL MEDICINE, CORNELL UNIVERSITY MEDICAL COLLEGE.

THE first twenty-seven cases of cerebrospinal meningitis admitted to Bellevue Hospital during the present epidemic yielded twenty-four deaths, or 90 per cent. mortality. This appalling death rate made the visiting physicians anxious to try any method of treatment which promised better results. In the Lancet of November 1, 1902, Seager published an account of what he had witnessed in Lisbon during an epidemic there. In the beginning of the Lisbon epidemic, treatment by hot baths and ice to the head gave a mortality of 60 per cent. Then simple puncture of the spinal canal was tried in twenty cases. Of these, nine patients died. Of the eleven who recovered, one was deaf, one had persistent paralysis of the left arm, and four had bed-sores. The next seven cases were treated by puncture and removal of the fluid and an injection of oxycyanide of mercury. Of these seven, four died. The treatment by lumbar puncture, aspiration of the exudate, and injection of lysol in 1 per cent. solution was then adopted. Of thirty-one cases submitted to this treatment, thirteen died, and the eighteen who recovered were completely cured.'

At a stated meeting of the Section on Medicine of the New York Academy of Medicine, Dr. Morris Manges gave the detailed histories of three cases which had recovered under the lysol treatment."

Considering that the mortality in different epidemics of cerebrospinal meningitis has varied from 20 per cent. to 75 per cent., it is very difficult to draw conclusions from any treatment. A régime in which we may take great pride during one winter's experience with any infectious disease, may ride us to a bad fall in succeeding years. A postmortem study of the brain and spinal cord of a fatal case of spotted fever will also make one skeptical of the value of any alleged specific. And when we read' of nine consecutive cases of this disease recovering, without defect of special senses, under inunctions with an ointment containing an organic silver salt, "not begun until grave symptoms appeared," we can only regret that the author's delightful therapeutic optimism is not as infectious as the disease under consideration. Netter's seven cases of recovery, only five complete, however, under repeated lumbar punctures and baths at a temperature of 100° to 104° given for twenty or thirty minutes every third or fourth hour, night and day, make a more rational appeal to our understanding. The value of repeated lumbar punctures has also been emphasized by Koplik. Bela Angyan believes Quincke's puncture to be a rational method, but confines his own treatment to the use of the ice-bag and the subcutaneous injections of bichloride of mercury, made daily along the course of the spinal column.1 He reports 70 per cent. recoveries in twenty-seven cases under this régime. Wentworth is quoted by Osler as never having seen any cases benefited by lumbar punctures, though constantly on the watch for them. Osler himself speaks of benefit as being possible by withdrawal of cerebrospinal fluid, and thinks that in certain severe cases laminectomy and drainage would be justifiable.

In estimating the possibility of beneficial results from intraspinal injections of lysol, we must consider what lysol is, how it may act, and what danger may attend its administration. Lysol, which is obtained by dissolving in fat, and subsequently

purifying with the addition of alcohol, the fraction of tar oil which boils between 190° and 200o C., is a brown, oily-looking, clear fluid, with a feebly aromatic, creosote-like odor. It is said to be five times greater in antiseptic power than carbolic acid, and eight times less poisonous. Gerlach of Wiesbader found that 2 per cent. solutions of lysol diminished the growth upon gelatin of spores of anthrax bacillus in one hour, up to complete arrest of growth in six hours. Much weaker solutions arrested the growth of staphylococcus pyogenes aureus in fifteen minutes. Five per cent. solutions of lysol reduced the number of colonies in decomposing fluids from about 300 in 30 minutes, to 50 in one hour, and to zero in 6 hours. Lysol might then reasonably be expected to inhibit the growth of pathogenic microorganisms in the exudate of cerebrospinal meningitis, and the clinical proof of this was furnished by the published report of the results in the Lisbon epidemic."

That lysol is reasonably safe, even in much stronger solutions than had been employed in Lisbon, is also evident from its extensive employment in gynecological and obstetrical practice where the chances for its absorption from broken surfaces are very favorable. G. Burgl, in the Münchener medizinische Wochenschrift, gives two cases in which young children were fatally poisoned by teaspoonful doses of lysol, given internally by mistake. Burgl also collects 16 other cases of lysol poisoning from the literature. Of these 18 cases, 13 were produced by internal administration, of which 7 recovered and 6 died; 5 by external application, of which 2 recovered and 3 died. The largest internal dose which was followed by recovery was 60 grams in an adult, and 25 grams in a four-year-old child.

My own experience with the lysol treatment comprises the following cases:

CASE I.—Italian boy, seventeen years old. Admitted April 12 in delirious condition with history of sickness lasting four days and beginning with chill and severe headache. Examination showed marked retraction of the head, thighs and legs flexed, Kernig's sign present, opisthotonus when rolled over, slight nystagmus, herpes on lips, tongue dry, brown, and fissured, teeth covered with sordes, no cardiac murmurs, no pneumonia, superficial and deep reflexes exaggerated, tache cerebrale present, urine shows a trace of albumin, leucocyte count, 38,600, catheter necessary. Lumbar puncture was made and purulent fluid withdrawn, which gave pure cultures of the diplococcus intra-cellularis meningitides. After drainage 15 c.c. of 10 per cent. lysol solution was injected. The strength of this solution was due to an error, but so marked an amelioration of the symptoms followed the injec tion, and that without any evidences of lysol poisoning, that in subsequent cases the 10 per cent. solution was also employed. It must be remembered that all the cases were in adults. At the end of forty-eight hours the symptoms had again increased in severity, and a second injection of 15 c.c. of 10 per cent. solution was made. Again the symptoms seemed to be held in check, for a period of fortyeight hours, when a third injection of same amount and strength was made, with apparently a similar result. Three days now elapsed before a fourth injection was thought to be necessary, and after this, patient continued to improve steadily and left the hospital on May 5, 1904, well, except for left sciatic neuritis.

Was this a case showing the remissions common to this disease, or did lysol influence the result?

CASE II.-Englishman, forty years old, always a hard drinker, had syphilis sixteen years ago, had lost about thirty-five pounds in last five months. On