into the bladder, one is inclined to think, first of all, of Klemperer relates in the cited article cases of hematu a surgical affection of the kidney and, in the vast ma ria resulting from over-exertions, but his own observa jority of cases, one will not be disappointed in such a tions of hematuria due to bleeding from a strictly nor surmise. But, if upon careful examination by palpa mal kidney he classifies in two categories: 1. Hemo. tion and percussion and the chemical examination of philia. 2. Angioneurotic hemorrhage from the kidney. the urine and, in some cases (malaria, filaria sanguinis), He diagnoses angioneurotic hemorrhage from the kidthe blood, no pathological condition can be determined, ney if the bloody urine is a simple mixture of blood and if there is no pain, and no cachexia, nor other sub and urine without any other pathological ingredient and jective symptome, the differential diagnosis must be the palpation of the kidneys does not reveal any enmade between three different affections. It must first largement The real origin of the hemorrhage is deter be determined that the individual is no bleeder. Sec- mined by sensitiveness of one kidney, erythocyte cylin ondly, whether it might be likely, in case there be a ders or cystoscopy. Signs of a general neurasthenia hereditary tendency, that the patient be a local bleeder. support the diagnosis but need not necessarily be The latter is undoubtedly an exceedingly rare occur present. rence; but one well authenticated case is mentioned in "Twentieth Century Practice "1 -a case that was re lated to Osler by Hayes Agnew-in which the patient manifested the characteristic, with difficulty controllable bleeding upon cuts above the neck only and never from those below that part of the body. Senator' has reported a case of hemorrhage from one kidney which he diagnosed as "renal hemophilia" and which ceased upon removal of the affected kidney.

A third class of bleeding from one kidney in appar ently healthy individuals has been described by Klem perer; we refer to the bleeding which is due to nervous influence, an angioneurosis, in which there usually are, but not necessarily, other symptoms of a neurotic char acter. Klemperer relates from literature eight cases of profuse hemorrhage from one kidney where, upon operative procedure, no pathologic changes could be demonstrated in that organ. He believes that all of them must be attributed to the influence of the nervous sys tem, a vaso-motor paralysis. To substantiate his theory he refers to animal experiments as well as clinical ob servation of angioneurotic hemorrhages in other parts of the body. Regarding the above mentioned case ob served by Senator, Klemperer doubts the propriety of classifying this case as a local hemophilia and is in clined to classify Senator's case as an angioneurosis since the family history is not one of unequivocal hemo philia.

Hemorrhages from the kidney due to over-exertion, while they may occur in healthy individuals, can not be strictly classified as coming from a healthy organ. It is due to congestion and rupture of blood-vessels. It is a transitory form approaching somewhat the condition of traumatic hemorrhage. Hemorrhage from the kid ney due to over-exertion does not seem to have been described in literature and, according to Klemperer, Leyden was the first who called attention to it in his clinical lectures, in which he usually related the case of an old physician, who had transitory hematuria after mountain climbing which rapidly disappeared.

'Twentieth Century Practice, Vol. VII, p. 519.

2 Berliner Klin. Wochenschr., 1891, No. 1.

Deutsche Medic. Wochenschr., 1897, No. 9, p. 129. 'Loc. cit.

Angioneurotic hemorrhages from one kidney have also been observed in which there was pain and which therefore presented the greatest resemblance to colics that are due to nephrolithiasis. They are distinguished from the latter by the lesser intensity and the shorter duration of the pains and by the fact that they may be beneficially influenced by suggestion The diagnosis of angioneurotic hemorrhage from the kidney can only be advanced after weeks of observation. Their treatment consists in absolute repose in be, a predominating, not exclusive, milk diet and well directed psychic treatment by suggestion. Hydrotherapy—a warm bath with cold douche, is much to be recommended; possibly also elec tric treatment. Exploratory incision is indicated if, after weeks' of internal treatment, no cessation of the bleeding takes place and the resulting anemia endangers the life of the patient. Should, upon an exploratory incision, the kidney be found normal, the wound must be closed and the effect of the operation awaited before the kidney should be extirpated.

The treatment proposed by Klemperer is undoubtedly based upon logical reasoning. The curative effect of surgical operations upon the bleeding of healthy kidneys, in cases where the hemorrhage is due to an angioneurosis, can only be explained upon the basis of a psychic influence, upon an influence by suggestion, and where such an influence can be exerted by milder means than that of an exploratory incision, so much the better. In hemorrhage from the kidney due to a general hemo philia, all operative interference, even cystoscopic examination, is, of course, contraindicated. Local hemophilia is by no means a generally recognized condition and the above mentioned case of Agnew and that of Senator are probably the only ones on record. Senator's case, moreover, as Klemperer very pertinently points out, is not unobjectionable with reference to its classifi cation as a local hemophilia; so that in reality Agnew's case is the only one remaining.

Klemperer does not include local hemophilia of the kidney in his classification of these conditions which may be the cause of chronic nephrorrhagia from a healthy kidney but admits only the hemorrhage due to a general hemorrhagic diathesis and the angioneurotic form. Considering, however, the absolute reliability of such a source as Hayes Agnew, the possibility of a

sisting of an equal proportion of members of the medical profession that are connected with medical colleges as teachers or assistants to that of the physicians of the State not connected with medical colleges. If, for in stance, the proportion of professors, lecturers and their assistants in the State be in proportion to all reputable physicians of the State as one to twenty, then the com. mittee should consist as near as feasible of an approxi mately similar proportion of members whithin and without of medical college circles.

nephorrhagia being due to local hemophilia should be medical college faculties of this State, but also by mem. considered, and it appears that in classifying chronic bers of the medical profession who are entirely free hemorrhage from a healthy kidney the possibility of a from college ties. We would suggest that a committee local hemophilia of one kidney must be, theoretically be appointed at the meeting of the State Society conat least, admitted, and in classifying cases of which little or nothing has so far appeared in text books, local hemophilia, it seems, should not be ignored. Whilst from the foregoing it is plain that hemorrhage from healthy kidneys may occur, the fact must not be lost sight of that, ordinarily, one has to expect some determinable pathologic anatomic or abnormal condi tions, and among these in persons with no subjective symptoms, sarcoma of the kidney is a frequent cause of hemorrhage. Israel, of Berlin, relates a number of cases observed at the Moabit Hospital where in otherwise ap parently healthy individuals bleeding was due to small sarcomata, which could be detected by careful palpa tion. Hemorrhage due to stone is readily recognized by the severe and characteristic pain.

In every case of hematuria it is, of course, necessary to inquire into all the various conditions that may cause hemorrhage from the kidney or bladder and in addition to those conditions already referred to must be men tioned acute nephritis, tuberculosis, pyleonephritis, tu mors (papillomata of the bladder), psorospermiasis, distomiasis (of Egypt). In individuals that are apparently healthy or subjectively well, angioneurotic conditions, general and local hemophilia, sarcoma, papilloma of bladder and, possibly, malaria would have to be princi pally considered.

Whilst it is well to know that hemorrhage from the kidney may be a comparatively harmless condition it must not be forgotten that such conditions are rare and that in each individual case of hematuria the greatest care is necessary in order to arrive at a correct diagnosis. Over the possibility that in nephrorrhagia both kidneys may be healthy, the important fact should not be lost sight of that in the overwhelming majority of cases it is due to a local pathological condition in which surgi cal interference may be necessary.

In formulating future laws for the State the medical profession should look around among the other States of the Union where laws are already in existence which, carried into practice, have been satisfactory in their results-not with a view of perpetuating inadequately equipped colleges, but with that high and only correct aim of meeting the demands of modern science and a thorough practical medical education in the laboratory as well as at the bedside.

Members of the medical profession of the State of Missouri, study the system that has been in vogue for years in the State of New York, before you decide upon a law that is to regulate medical education in this State. Do not listen to those who hold that the laws governing medical education in this State must be adjusted to that of neighboring States, lest college faculties would have to go begging for students and the "commercial" interest of the State would thereby be interfered with. Do not blindly follow into the footsteps of your neignbors and do your own thinking!

All the good intentions and untiring efforts of the State Board of Health have been annihilated by the decision of the Supreme Court. All the many articles and discussions in the daily press for and against the good work of the State Board of Health has been in vain! But, let us see, possibly not entirely so. The public and also the medical profession have become better ac

The Defeat of the Missouri State Board quainted with this question. They have thereby been

of Health.

aroused to the importance of the matter. The public has not been blind to the various points in the contro. versies and it is to be hoped that all family physicians may enlighten their patients with regard to these controver sies. Such methods are more effective and thorough than all the newspaper articles, of which the intelligent part of the public at least knows that they are often misleading.

Whilst it is to be regretted that the Supreme Court of this State has declared the most important provisions made by the Missouri State Board of Health with regard to the regulation of medical education in Missouri, unconstitutional, there is now a hope at least that the entire medical profession may make an effort to influence legislation in the proper direction. At the present With a united action of the entire medical profession phase of development of this question every physician of this State medical legislation will sooner or later be of this State can not be too earnestly urged to take a properly adjusted and for whatever its standard be in personal interest in future medical legislation. We the future the profession will be held responsible; for hope, therefore, that the profession will be numerously it has the power and right, nay-duty, to shape its own represented at the meeting of the State Society, as such destiny.

an important matter should be freely discussed at its Natural evolution points toward few but well equipped meeting and not only by members of the numerous and abundantly endowed medical educational institu

tions. It is true that concentration of power is, under most the exercise of doubtful and indiscreet power delegated circumstances, to be deprecated; but in matters of education, especially medical education, evolution teaches the fact that such concentration of power will be, in this one exception, welcomed by every individual. It appears, moreover, that concentration of power, as ap. plying to educational institutions, may be so shaped and modified by intelligent and just legislation, that it will be a blessing instead of an objectionable feature in the final product of the evolutionary process in educational institutions.

That natural evolution will accomplish, therefore, a satisfactory legislation sooner or later may be with certainty expected, but the earlier each individual member of the profession takes an active part in a thorough and righteous settlement in the matter, the sooner will this evolutionary process be accomplished and the better it will it be for all concerned.

The Appointment of Homeopaths at the
State Lunatic Asylum at Fulton.

to him by legislative authority, has seen fit to depart from the honorable prestige of his worthy predecessors and displace from the control of the State Lunatic Asylum No. 1 those whose influence and ability made the Asylum one of the great charities of the West, placing it under the control of the homeopathic school of medi cine and in the persons of those devoid of experience, illiberal and sectional in science and art; we, the physi cians of the Central District Medical Society of Mis souri, an organization for the advancement of true and genuine science ond in behalf of the common afflictions of humanity, express our regret that the highest officer in the State should lend himself to the infatuation of factional science and to the hallucination of unscientific imagery; therefore, be it

Resolved, That by this act of the Governor he has forfeited the respect and esteem of all lovers of science and humanity, as well as the impartial citizenship of the State.

Resolved, That this procedure on his part indicates a mental condition which fails to appreciate the mission of the science of rational medicine.

The action of Gov. Stephens of appointing homeo of that unfortunate element in social life who are de Resolved, That he fails to appreciate the condition paths in charge of the State Lunatic Asylum at Fulton, prived of their reasoning powers, subjecting them to can not be too strongly condemned by evey intelligent the management of an inexperienced corps of experi. menters, who lurk upon his favor for reward.

person. That medical educational institutions outside

of the regular scientific school should be recognized in any of the States at this phase of evolution in medical science is strange indeed, but when representatives of sectional medicine are appointed to official positions, it is time that every lover of science and therefore oppon ent of all kinds of dogmatism in medicine and all other sciences should enter an earnest and most emphatic pro test against such ignorance and barbarism. It is strange that a person who appears to be unable to differentiate between scientific medicine and dogmatism should be the governor of a State. His action can not be too severely criticised and reprimanded. It is expected that the State Medical Society will take a firm stand in the matter and will express an unembellished as well as unequivocal opinion.

Gov. Lon V. Stephens and State Lunatic Asylum No. 1, at Fulton, furnished the topic of a lively discussion at the quarterly meeting of the Central District Medical Society of Missouri, held at Sedalia, Mo., May 5. In the absence of Dr. G. W. Holcomb, of Clinton, Presi dent of the Society, Dr. F. DeVilbiss, of Spring Garden, Vice President, presided, with Dr. A. F. Dresel, of Sedalia, as Secretary.

The following resolutions were unanimously adopted:
WHEREAS, His Excellency, Gov. Lon V. Stephens, in

Resolved, That by the unwarranted innovation upon the helpless occupants of charity of the State, he has prostituted his high office for base purposes and unmanly motives.

Resolved, That we, by these proceedings, in the name of science and the interest of our common humanity, do enter our solemn protest against the exercise of power by a bewildered partisan, receiving and holding his office by the suffrage of a free and intelligent people.

Resolved, That this Society approves the conduct of Drs. Young and Biggs in refusing to resign their posi tion except for cause.

A resolution providing for forwarding the resolutions to Governor Stephens was defeated, it being deemed advisable to let the State Association apprise him of the action taken.

Anti-Cigarette Bill.-As soon as the City Coun cil gets in regular working order an anti-cigarette bill will be introduced. A measure is now being draughted by several prominent attorneys, which, if adopted, will prohibit the selling of cigarettes or cigarette paper to minors in the city of St. Louis. The bill is being fos tered especially by the Woman's Christian Temperance Union, and Mrs. F. H. Ingalls, President of that body, says that the matter will be pushed until the city legis lators take the desired action. This is in line with similar anti cigarette legislation in other large cities.

MEDICAL SOCIETIES

PROCEEDINGS OF THE ST. LOUIS
MEDICAL SOCIETY.

Stated Meeting, Saturday Evening, April 10, 1897, the President, W. J. LANGAN, M.D., in the chair.

*

Dr. Joseph GRINDON read a paper on

Extra-Genital Chancre,

cated to the young girl by the young man, although at the time I examined him I could find no evidence of the disease about his mouth. I lost track of both of them and do not know whether he ever developed the disease.

them with a wretched mouth. It was a fact that I was treating the three young men at the time who participated in the communion in this one church.

I have seen five cases of labial chancre in innocent women, and one case in a woman whom I do not believe was innocent, although she was not a prostitute. I, the other day, asked Dr. Grindon if a chancre on the womb would be considered a genital chancre, and he said it surely would, but it is very rare. I have seen one case of chancre of the womb; I think Dr. Homan saw the case with me, and this woman afterwards developed syphilidæ, mucous patches and other signs of syphilis. I suppose most of the members, like myself, have been Dr. Frank R. FRY.-I think that I, for a general at times the recipient of literature from individuals who practitioner, have had an unusual experience in extra were attempting to gain data about the probability of genital chancre. I have seen two cases that I think are the communion cup communicating syphilis. It seemed worth relating. One was the case of a lady who came to me that in their attempt there was something sensa. to me with the glands of the neck enlarged, although tional, yet, they might have had an honest purpose. I she made no complaint of sore throat until I started to can understand why a communion cup would be the look into the throat, then she said that her throat had more frequent source of communicating syphilis than been hurting her some when she swallowed. I saw just the beer mug; the cup passes from lip to lip without at the lower edge of the tonsil a circular lesion which being washed, the beer mug is washed between drinks. looked very much like a chancre. The tonsil was very I once told a clergyman that I knew three gentlemen slightly inflamed, it seemed to me, and not much larger communicants at his altar who had syphilis, and one of than its fellow; the amount of local inflammation was slight. In the course of a few weeks she broke out with syphilidæ, which was very obstinate. She has been under treatment regularly ever since. This is the only case of tonsilar chancre that I ever saw. Another case occurred in an innocent girl who had a chancre on her lip. The appearance of the sore and the swelling in the neck left little doubt in my mind as to the character of the lesion. She told me she was keeping company regularly with a young gentleman, whom she allowed to kiss her, and to whom she was en gaged. I told her to send the young man to me if he would come. He came and I told him my suspicion; he insisted that I make an examination to see if I could discover any evidence of syphilis in him. I made a careful examination of his body and his mouth but saw no evidence of syphilis in the man. I told him that I could not understand the situation. The young lady had given me permission to speak to him after I told her of my suspicions about it, and she said the only way she could have gotten it was from this young man. As he was about leaving my office, he said he wanted to make a confession and stated that he bit that girl on the lip where the sore appeared; he remembered that he made a lesion, and where he bit her the chancre ap. peared. I told him to come around occasionally and he did several times, but I never saw any evidence of the disease on him.

In the course of a short time, I do not remember exactly the number of days, the girl broke out with syph. ilidæ, she lost her hair completely, so that she had her head shaved and wore a wig. It seemes to me there is little doubt that the syphils in that case was communi

DR. JACOBSON.-I have only seen two cases of tonsilar chancres in my own practice, and those were when I was at the City Dispensary. I have now a case under my treatment that developed about three months ago a chancre of the lower lip. It was a well-marked chancre, still I waited until the secondary symptoms developed before I put her under treatment, although it was very provoking to her to have to wait, as she is an actress, that is, a chorus girl, and she depends on the stage for her living, and, of course, can not work so long as she has the sore on her lip. She was very anxious to have something done, but I could not give her anti-syphilitic treatment until I was sure.

During the last ten years I have treated, I suppose, and seen in the hospitals about twenty cases of extragenital chancres, but they were nearly all found on the lower lip, one on the upper lip and two on the fingers of men. One was a baggage car clerk, who contracted a chancre on his finger and the ulceration extended around the nail and, as a result, he lost the nail. In about six weeks he developed secondary lesions. It has been stated by some of the older writers that chancre of the scalp does not occur, but lately that has proven. to be false. It is possible to have chancre on any part of the body. They have been found in the rectum, on the nose, breast, fingers, toes and any part of the face, etc., and it has now been found that it can be communi. cated to the doctor in making a post mortem shortly after the death of a syphilitic patient. I did not be. lieve that until I read some reports upon the matter.

that case it was the result of oral coitus on the part of a young married mau in his wife's throat; the right ton sil had a chancre upon it from which she developed

There are also cases reported of extra-genital chancres extra-genital chancres; still, it is well for the profession in the Eustachian tube communicated by the instrument to be reminded of it, otherwise they are very apt at used in inflating the middle ear. Lee reports chancre times to be overlooked. It has been my fortune to see of the scalp, and Ring and Messig of the eyelids. Os- a great many cases, but only one tonsilar case, and in ler had two cases, one on the tongue and one on the tonsil, and Peters reports three cases of chancre of the scalp in children. In children chancre is very often overlooked, as we would not expect to find syphilis in syphilitic symptoms. It was a very disgusting state of children unless it was hereditary; the primary lesion is very rare. Of course, it may occur from contact with various articles, as the essayist reports, possibly through cloths, and cups, or other eating utensils. A French physician also reports three cases of chancre of the scalp in children; so we see the primary lesion may oc cur in any part of the body, and we must always be on the outlook for it. As Dr. Grindon says, when sores do not yield to ordinary treatment they must be looked upon with suspicion, and as soon as secondary symptoms appear, the diagnosis is clear.

DR. WILLIAM JOHNSTON.-I would like to ask these three gentlemen if, in these cases of extra-genital chan cre, they can make a differential diagnosis between soft and hard chancre in different parts of the body?

things. I have seen chancres on the lips, probably ten or a dozen times; on the nose, on the cheek and on the ears, and to day I was reading the report of a case of chancre upon the toe, which struck me as a very extraordinary thing.

As to the greater severity of the subsequent symp toms in these cases, I know of no reason why the symp. toms that follow these extra-genital chancres should be any more severe than those upon the genitals, still experience may demonstrate that they do develop more serious symptoms or more virulent features. So far as I have seen the chancres that occur about the face present the usual characteristics; there is the marked indaration and the comparatively slight discharge which is so characteristic of the Hunterian chancre, differing, so DR. FORD.-I would like to ask these gentlemen who far as I know, in no respect from chancres upon the geni. have seen skin chancres, if they will describe their gen- tal organs except as to the character of the tissue that eral appearance. It is important to recognize the cuta is involved. As to the differential diagnosis, my friend, neous chancre as early as possible, and it differs some Dr. Johnston, refers to between chancre and chancroid, what in many respects from chancres of the genitals. I I believe he does not recognize that there is a dual poirecollect of seeing a notable case of that kind which son, I think he does not recognize that there is any dif occurred here in a medical man whom we all knew, and ference between chancre and chancroid. For my part, I believe he was once President of this Society. He I think they are very distinct things, and the clinical first approached me, and on his right hand he bore a history is usually very different, it is especially differ sore with moist indurations, and the axillary glands on ent in the typical forms of these different ulcers; there that side were enlarged. The character of the indura is as much difference between chancre and chancroid as tions were so peculiar that I could not refrain from pro as there is between measles and small-pox. In the typ nouncing them chancres. He afterwards went to Dr. ical Hunterian chancre there is a clear surface, with Gregory, who expressed the same opinion, and we all marked induration; whereas, in chancroid, it is a little know the history of the case. He treated himself for ragged ulcer, secreting freely purulent discharge and several years, and, finally, when he found his nervous presenting a marked destructive surface, widely differsystem was being invaded by the hopeless condition ent. Now, I do not mean to say that you can always which is characteristic of late nervous affections, his distinguish between an infecting sore and a non-infect courage failed him and he committed suicide. The ing one, because I know there is a shading off as be. characteristic appearance of the cutaneous chancre is tween the typical chancre and the typical chancroid, and such that, I think, in conjunction with the enlargement it is sometime impossible to make a diagnosis unless of the glands of the axilla, perhaps, and indications you wait the regulation time for the development of elsewhere, we can make a diagnosis pretty well quite early. Still the appearance of the cutaneous indura tions may sometimes be dispositive. I would like to hear what these gentlemen have to say about that.

DR. Ross. It was formerly supposed that extra-genital chancres were more severe than genital ones; I have been unable, in looking up literature to verify this sup position; but a month ago there appeared in one of the journals an article from one of the hospitals in Paris, where a record was kept, showing that in these cases the syphilis was no more severe than in genital cases.

DR. PREWITT.-It is well to have these matters brought to the knowledge of the profession and kept before their minds, because it is very unusual to find

secondary symptoms, but that they are caused by two distinct poisons, I think there can be no question, and when we are called to a case which has had an initial sore, and there is subsequently a development of secon dary symptoms, I believe it is a case of true syphilis. All of us know that the period of incubation varies, the usual period is from 9 to 21 days, but it may be longer; in one case in my experience it took 35 days, and I have no reason to question the statement made by the young man. I have met with cases often where the appearance of the sore indicated a non-infecting simple chancroid, and yet later, secondary symptoms devel oped, and, as is generally found, the induration appears at the base of the sore, and it indicates to my mind that