sion and pressure this organ may have lost peristaltic ability and in that event. it should always have artificial help, and no obstetrician has performed his whole service until he has looked after this. Such attention is only required for a short time, but that time is of great importance. As soon as consistent the new mother should be gotten into the open

There is no rejuvenant equal to fresh air and sunshine; there is no single means of physical improvement more helpful than systematic deep breathing and one of the special instructions to a patient convalescing from confinement should be to breathe deeply. The habit of frequent douching of the parts is to be deprecated, excepting in cases of absolute infection.

If the Great Architect had intended a flushing system connected with the generative system, he would have provided it when he built the house. Much washing not only removes lymph that is necessary to the repair of torn parts, but it also dilates and weakens them, and as the discharges are natural and if normal are not unclean, the only thing that is really essential is the keeping of the external parts clean. Better by far give attention to the changing of clothing, the removal of napkins and the cleanliness of external parts than to the douching of internal ones.

It is a custom in the country and likewise in many of the cities, to make the day following child-birth a receiving day for callers. This habit is likewise very objectionable. The mother who has been through the greatest strain of her life should be kept profoundly quiet and especially from the necessity of either physical or mental strain.

It is the little things, after all, which make the whole and the best after-treatment of the obstetrical case is that founded upon common-sense and reasonable judgment.

Simplicity in dress, care in exercise,

regulation of general habits and consistency in all things will do more for the new mother than all else combined.

RHEUMATIC INFECTION.*

W. B. HINSDALE, M. D.

ANN ARBOR, MICH,

Since the microbe was discovered in association with morbid changes, it has risen in the mind of clinicians from the rank of a suspicious influence to first place in the etiology of acute diseases. It had been suspected for a long time that many diseases might be excited and spread by material agencies. When it became demonstrated that such is the case, in very many instances, the study of their symptomatology led to the recognition of a group of characteristics, which being found in any acute illness of uncertain origin, classifies it hypothetically with them. In medicine we have to reason by inference, deduction, exclusion and analogy. Bacteriologists have demonstrated the relation of cause and effect between certain known micro-organisms and certain diseases. Inference has frequently led to demonstration. When certain symptoms are found common to a large number of infections it is a safe deduction that those symptoms, if they be constant and numerous in other diseases, are evidences of the infectious nature of these diseases, although in them the specific organism be not yet verified. The most valuable aid to medical research is the working hypothesis. The foregoing hypothesis has led to the discovery of many specific causes of diseases. Among other things, it leads one to infer from clinical evidence alone that the complex of symptoms commonly called rheumatic fever belongs to the infectious class.

Among the symptoms which are common to and significant of acute specific infections may be mentioned: (a) A primary localized irritation, usually spread

*Transactions of the American Institute of Homeopathy.

ing and involving other tissues; (b) Pyrexia, due, presumably, to toxins; (c) Pain and delirium, due to nerve and cerebral irritation, also presumably toxic: (d) Running, when uncomplicated, a self-limiting course; (e) Tendency to renal, pleuritic, arthritic and cardiac involvement; (f) More frequent occurrence during childhood and adolescence; (g) Epidemic occurrences; (h) Liability to an eruptive stage.

Acute rheumatism in its full expression may have all, and does have many of these symptoms; therefore, if there are no positive reasons for calling it otherwise, the strong infrence is that it is a distinct, infectious disease with a specific cause and reasonably constant symptomatology. We do not believe that many nowadays seriously think of rheumatism as a neurosis, or as being caused by a retained acid originating in defective metabolism.

Some comparatively recent opinions have been given that, after all, rheumatism is only a chain of accidental painful events associated with other diseases, exposures or coming as sequelæ. Rheumatism and rheumatic have been used as loose expressions to describe pains and aches in various parts of the body, especially if centering in the joints. Perhaps a dozen different conditions have been covered by these charitable terms. Time does not permit more than the mention and condemnation of such loose uses of words.

Of course it goes without saying that until the specific organism of an infectious disease or its products be discovered, the diagnosis of that disease is not absolutely certain. We must, when such demonstration is lacking, depend upon subjective and objective manifestation, always, of course, reasoning by exclusion. In the case of rheumatic fever, as in scarlet-fever, measles and mumps, we rely, at the present time, upon the symptomcomplex for diagnosis, but must reject arthritic, myalgic, tonsillar, choreic, renal

and cardiac symptoms common to rheumatism if they are known to be accompanying the gonococcus, tubercle, typhoid and other bacilli. There is no reason of applying the term rheumatic to the afterpains and arthritis of diphtheria, typhoid and scarlet-fevers, small-pox, septicæmia, etc., unless it be demonstrable that either rheumatic infection can become engrafted, or that rheumatism is only a kind of "condition," like the typhoid condition which may arise in the course of any of the specific acute fevers.

To this point only the presumptive evidence favoring the classification of rheumatism with the infective diseases has been put forth. Almost any text-book of internal medicine, of recent date, will corroborate the views expressed. A few citations may be allowed.

Dr. Henry Koplik (Diseases of Infancy and Childhood, 1902) makes this statement: "Although acute articular rheumatism is still regarded by some authors as a constitutional disease caused by disorders of nutrition which result in local manifestations, the general tendency is to regard it as an acute infectious disease.'

Dr. F. Mortimer Lawrence (Practice of Medicine, 1901) gives the exciting cause of rheumatic fever as a micrococcus entering the body through the tonsils and wounds. Dr. Herman Eichhorst, Professor of special pathology and therapeutics and director of the medical clinic in the University of Zurich, (A TextBook of The Practice of Medicine, 1901) says of the etiology of rheumatism: "Exposure to cold was formerly considered the cause of acute articular rheumatism. Recently, however, the disease has been properly included among the infectious diseases, and the time has therefore arrived when the old inappropriate designation may be dropped and possibly replaced by that of acute polyarthritis." In The Journal of Pathology and Bacteriology, December, 1903, p. 158, W. V. Shaw, M. A., M. D., of The Welcome

Research Laboratories, states: "The clinical features of rheumatic fever, especially the disease seen in childhood, undoubtedly point to an infectious origin of the disease." In another connection he says: "Only a specific infective process will account for all the lesions of clinical rheumatism."

Perhaps the investigators who have given as much attention as any to this subject are Doctors Poynton and Paine, of London. They make the following statements as results of their investigations:

(British Medical Journal, September 21, 1901, p. 779) "The microbic origin of rheumatic fever has met with such general acceptance in this country and on the continent that there is no need to recapitulate the reasons in favor of this view." They state further: "An advance can be made from the position that rheumatic fever is due to a bacterial infection, to the position that it is due to a diplococcus infection. The exact place that the diplococcus will take in the coccus group may take some time to ascertain with certainty, but it seems more likely to lead to an advance in our knowledge if we look upon it as specific, rather than if we regard it as an attenuated form of some other coccus infection."

Poynton and Paine isolated a diplococcus which, injected intravenously into rabbits, produced polyarthritis, carditis, chorea and other symptoms associated with rheumatic fever. Shaw also experimented with cultures obtained from fatal cases of rheumatism, and in twenty-five rabbits confirmed Poynton and Paine's micrococcus. He also made confirmatory tests upon monkeys. Shaw concludes his thesis thus: "Acute rheumatism is therefore of microbic origin, the actual -causal agent is a micrococcus resembling the streptococcus pyogenes in its chief characteristics."

Times do not permit the citations of other authorities upon this part of the subject. Sufficient references have been

made to indicate a quite general acceptance of our contention upon the part of clinicians who have made special researches during long periods of time.

Supposing that rheumatism be an infectious disease of a definite type, the pertinent question is: How does the infection gain admission to the body? The pathologists already quoted are quite definite in their replies to this inquiry. The tonsils are supposed to be the usual, if not the only avenue for admission. These glands are recognized to be of great importance, both as conservative and pre-' disposing agents. When normal, they are conservative because they are the seat of active phagocytosis; when abnormal the phagocytes are paralyzed and permit invasion to take place, as through a wound. Tonsillar inflammation is a symptom associated with many acute diseases, one of which is rheumatism.

The fully developed attack of rheumatism is sometimes preceded by several days by a preliminary tonsilitis. The initiatory tonsilitis, when present, appears as a kind of "primary lesion," being followed by arthritis, choreic symptoms, valvulitis, leucocytosis, eruptive stage and pyrexia. Dr. Poynton (International Clinics, Vol. II. 1903) expressed himself as follows upon this point: "The physician has long recognized the association of a sore throat with rheumatic fever, and I think that all English clinical authorities, experienced in this disease, admit the fact." ... "There is but little doubt that the micro-organisms gain access to the cardiac valves by making their way from the tonsil into the blood-stream and then they survive and multiply in these tissues which favor the rheumatic infection."

It might be an allowable digression in this connection to give Poynton's explanation of the more frequent involvement of the mitral valve: "It is the most complex in structure and contains minute blood-vessels, in which the diplococci travel to the tissues of the valve. The

aortic comes next, in part, because of its proximity to the mitral."

Dr. St. Clair Thomas (The Practitioner, January, 1901: "Rheumatic Fever in Relation to the Throat") in an exhaustive article makes a few statements that are here presented: "We have brought before us two different, but not necessarily contradictory, points of view. The first is, that in a considerable number of cases of rheumatic fever the poison enters the system through the tonsil, the inflammation of which may be the earliest indication of the systemic infection. The second is that certain inflammations of the tonsil occur with greater frequency in patients with an arthritic diathesis."

At the close of his discussion he draws the following conclusions: (a) A number of acute cases are preceded by angina in a proportion from 30 to 80 per cent.; (b) The connection of angina with rheumatism, though undoubted in a number of cases, is not yet clearly established; (c) The tonsil may be the port of entry of rheumatic virus, and this though the naked eye appearance of the throat gives no indication of affection; (d) The par

ticular affection of the throat which is associated with rheumatism is not yet established, but it is not quinsy; (e) The question requires further research in two directions. One in differentiating the various forms of angina and determining the one associated with rheumatism, the other in further research to discover the true nature of rheumatism.

Against the supposition that infection. gains admission through the tonsils to the blood and lymphatic circulations can be urged the fact that the tonsils practically disappear in adults, and that a large percentage of cases do not have the preceding or associated symptom of tonsilitis. To the first of these objections it may be urged that the throat in various parts, at all times of life, contains tonsillike tissue through whose lymph-spaces infection is always possible, even though the real tonsil gland atrophy. As a re

ply, in part at least, to the second difficulty may be suggested the possibility of the organs allowing infection to be received and transmitted to the circulation without noticeable local irritation. Again, cases are on record in which post-mortem central foci of inflammation have been found in the tonsil that had escaped notice during life.

SUMMARY.

By analogy, the symptom-complex of rheumatic fever lends a strong presumption to its being of an infectious

nature.

2. The testimony of competent observers, especially in England, where arthritic diseases, particularly gout and rheumatism, are very prevalent and require close clinical differentiation, goes

to show that from the tonsil, heart tissues, articulations, pleura, and other parts of the human body a diplococcus can be isolated which seems different from all other known specific cocci.

3. This diplococcus when injected intravenously into animals of various kinds produces rheumatic-like lesions which resemble symptoms of rheumatism in man as closely as animal lesion can resemble those in the human subject.

4. From 2 to 3 it is pretty conclusive that rheumatism is a specific infectious disease, the same as pneumonia and gonorrhea.

5. The infecting agent of rheumatism generally, if not always, gains admission to the body by way of the glandular structures of the throat.

THE TRUE PHYSICIAN is the man who treats his patients without reference to the remuneration that he shall receive, and the man who would arouse in the mind of the medical man the commercial spirit of the times ignores the interest of humanity and would lower the standard of the profession.

THE CLINIQUE

CH. GATCHELL. M. D. EDITOR.

DECEMBER, 1904

EDITORIAL

MEDICAL EDUCATION.

One of the conspicuous things in medical history during recent years is the rapid improvement in undergraduate instruction. It is trite to observe that the average medical graduate of today has perforce a more thorough and more comprehensive education than the one of twenty, or even of ten, years ago. Standards, both preliminary and collegiate, are higher, while facilities for study are greatly improved. The development of the collateral sciences, longer courses of study and improved teaching methods, all, of course, have contributed to this desirable result.

But to those who watch closely the trend of general opinion, it is apparent that while these benefits are admitted there is a persistent conviction that still other changes are necessary in the general plan of undergraduate instruction. There is still too frequent disappointment when the college-made doctor encounters the problems of actual practice. There is too often an exhaustive knowledge of disease, with a deplorable ignorance of what to do for the patient. Naturally this is less true of homeopathic graduates, drilled as they are in the study of individual symptoms and imbued as they all should be, with the clinical idea. But even homeopathic teachers do not all escape the dangers of ultra-theorism, and may sometimes

forget that they are training doctors for the care of the sick. For this purpose experience must always remain the best teacher, and the closer the college experience fits the subsequent experience in practice, the more nearly the ideal curriculum is attained.

Measured by this standard many of the best present-day medical courses must be considered faulty. In many the time is so occupied with purely theoretical or didactic work that clinical teaching takes a secondary place. In some the clinical instruction is entirely eliminated from the first two years, the student being deprived of all opportunity for the observation of disease during one-half of his medical course. The wisdom of these methods is being seriously questioned, and various alternatives are advocated. One is, the lengthening of the course to five years, making the first year one of preliminary study, covering parts of the work now done in the first two years. From a purely education standpoint this plan is a good one, but under present conditions any further lengthening of the medical course is hardly feasible.

In confronting this difficulty the question arises whether it would not be well to allow the student greater latitude in his choice of the work to be done before graduation. Under the present system in many departments he is compelled to do work that more properly belongs to the post-graduate specialities. Each instructor is prone to regard every student as an embryonic specialist in his particular branch, and insists upon the mastery of many technicalities that are