sions, it is his duty "not to hide his light under a bushel but let it shine forth," and if there be some matter or knowledge of his, that he believes will be of usefulness to other members, let him not hesitate to bring it to the society for consideration. Let not youth, or inexperience be a drawback, for as age guides the young, so does youth awaken maturity.

Do not let our proceedings become routine or "hum-drum," let them be bright and interesting as well as instructive. In these days of wonderful discoveries in the scientific work of curing the sick, and the vast amount of literature that comes under the observation and study of physicians, it not only is prudent, but it is necessary, that we be not too receptive, but be analytical of all medical matters; and therefore all discussions of scientific papers and articles must be given and received only in that way. Nothing should be right, because we wish it so, but be

cause it is so. No member must feel unkindly should any paper he may offer be declined by the executive committee, because it is their positive duty not to burden the members with any matter, which in their judgment, is of not sufficient merit to be presented at one of our meetings.

Before closing I wish to announce, that our proceedings will be recorded in the AMERICAN MEDICINE, and should any member desire to obtain reprints from the papers read, he will be able to do so at a very moderate rate from the publishers. 153 E. 81st St.

SURGICAL HINTS.

A small swelling in the parotid region may be an inflamed lymph-node. A single focus of tuberculous lymphadenitis is sometimes to be found here.-Am Jour. of Surgery.

ETIOLOGY AND DIAGNOSIS.

The Diagnosis of Acute Intestinal Obstruction.1- The occurrence of sudden abdominal pain, followed by cessation of bowel movement, without material rise in temperature, but with increasing frequency of the pulse, with abdominal distention, often local in the affected loop of bowel (Wahl's sign), and accompanied by visible peristalsis, often with nausea and vomiting, and without the tenderness and involuntary rigidity seen so typically in acute appendiceal, gall-bladder, and stomach lesions, should suggest acute intestinal obstruction with so much probability that we should avoid opiates if possible, withhold all food, and all cathartics by the mouth, and attempt to relieve the obstruction by enemas. At this time, as Ewald has shown, the stomach contains matter regurgitated by reverse peristalsis from the upper bowel, and the stomach washings should be watched for the first appearance of fecal odor.

Obstructions high up in the canal are generally characterized by greater pain, earlier nausea and vomiting, more flattening of the abdomen, scanty urine, and earlier collapse. Low obstructions are characterized by greater abdominal distention, oftentimes with prominence of certain portions of the abdomen, indicating that the entire colon is distended, or only certain portions of it, or only the small bowel. The prominence of a "horseshoe" of distended bowel in the course of the colon is very striking evidence of obstruction low down, while the absence of this and the presence of smaller prominent loops in the central abdomen suggests that the lower small bowel or cecum is affected. Previous operation suggests obstruction by bands or adhesions. A history of gall-stone disease suggests the possibility of obstruction by a large stone escaped by ulceration into the bowel. In the insane we think of obstruction through foreign bodies swallowed. In patients with diarrheal and dysenteric diseases the possibility of obstruction through masses of bismuth or other insoluble medicament is present.

'J. N. Hall, M. D., Am. Jour. of the Med. Science, Nov., 1910.

The presence of blood in the stools and a tumor in the abdomen in a young patient with obstruction of sudden onset suggests intussusception.

The beginning of the trouble after such exercise as skipping rope and certain contortions indulged in by boys in the gymnasium suggests a twist. A tuberculous history and the presence of palpable glands suggest obstruction by an acute process connected with a tuberculous peritonitis. A history of typhoid fever, duodenal ulcer, syphilis, or dysentery suggests a gradually contracting cicatrix with a sudden obstruction at the end. Gradual loss of weight and enlargement of accessory glands speak for cancer. Syphilis and toxemic conditions suggest the possibility of mesenteric thrombosis, and serious valvular disease and endocarditis the chance for mesenteric embolism. Blood is generally present in the stools in this class of cases, and was freely vomited in Case XX of my practice.

Early Symptoms of Tetanus.1— Evler (Berliner klinische Wochenschrift), in a serial article on tetanus, discusses first its early symptoms. He cites authorities like Rose and von Leyden. The consensus of view is that trismus must necessarily be present to insure a diagnosis of tetanus. Yet cases are on record in which trismus was absent, although tetanus of the arms, face and trunk was present. The author finds that the early symptoms of tetanus are transitory, vacillating, alternating. They comprise restlessness, timidity, night terrors, bad dreams, dysuria, dyspnoea, etc. The facial expression changes; there may be nosebleed, night sweats, prostration, yawning, vertigo-all symptoms of nervous irritability or prostration. Of more value are certain surgical symptoms. Thus swelling of an extremity, despite high elevation, is suspicious. The member in question may also be hot and painful. Lymphangitis commonly coexists. The blood-pressure is higher on the affected side. The injured limb shows such phenomena as contracture and tremor. Certain muscle groups are in a state of tonic spasm, often latent; that is, spasm appears only upon exertion.

1Medical Record.

The Symptoms of Exophthalmic Goiter.1-These may be divided, according to Woodward, for purposes of description, into circulatory, nervous, thyroid and ophthalmic.

Of these, usually the circulatory symptoms are the earliest developed. The most important of these is tachycardia. The pulse may range from 90 to 120, and in severe cases to 150 or even 200 per minute. It is usually regular, though Hewlett reports five out of a series of fifteen cases in which irregularity was present. Murray reports only 12 out of 180 cases, and A. Kocher only 4 out of 59 cases with irregularity. The apex beat is very forcible and diffuse, and gives the idea that the heart is greatly enlarged, because of its force being transmitted to the chest wall external to the apex proper. Some enlargement of the heart is usually shown by percussion, and, of course, this is more marked in the late stages of the disease.

In some cases murmurs are heard, esspecially in systole. These may be due to the dilatation of valve orifices, or in some cases to disease of valves. A sense of palpitation is often complained of, and there is often a visible pulsation in the abdominal aorta and femoral vessels. Venous and capillary pulse can often be made out. Flushing of the face and erythema of the skin are frequent.

Of the nervous symptoms, a fine tremor is the most generally present. It is very fine, eight or nine to the second. Vertigo, headache, restlessness, insomnia, increased irritability and hysterical manifestations are also seen, and in some cases acute psychic disturbances are present.

The thyroid is almost uniformly enlarged in these cases, though it may come on late in the disease. The enlargement is symmetrical usually, and that it is in part due to dilated blood-vessels is shown by the pulsation often present.

The eye symptoms are, in the first place, exophthalmos, the eyeball being pushed forward in its orbit sometimes to a marked degree. The palpebral orifice is widened so that the upper lid does not cover the entire sclera, giving a staring appearance to the face. Winking of the lids is seldom done,

1H. L. Woodward, M. D., Lancet Clinic, Nov. 5, 1910.

TREATMENT.

Ehrlich-Hata's "606."1-McDonagh in a very complete and interesting letter on the Pathology of Venereal Diseases gives his experience with "606" as follows:

"A new drug which bids well to revolutionize the present treatment of syphilis is engaging everyone's mind, the lay as well as the medical, and it is owing to the kindness of Professor Ehrlich that 1 am able to give an account of my small practical experience of its use. It is the outcome of years of patient work, and although christened with a somewhat unsightly namedioxydiamidoarsenobenzol-it is popularly known as Ehrlich-Hata's preparation No. 606. Its aim is not only to cure syphilis. after one injection, but also to prevent any recurrences. How far, then, are these ideals fulfilled?

That the lesions disappear in a most marvellous way may be seen from the following cases that I have had under my care:

CASE 1.-A man with a chancre, and no secondary symptoms, received 0.45 grm. of the yellow powder, and within 48 hours no spirochætæ could be found. After four days the chancre had cicatrised beyond recognition, and now, more than a month since the injection, no secondary symptoms have appeared.

CASE 2.-A man was admitted with a large indurated chancre of the prepuce, polyadenitis, sore throat, nocturnal headaches, and a macular rash.

Patient received 0.45 grm., and within 48 hours the headaches had vanished, throat was normal, rash on the road to disappearance, and the chancre had commenced to cicatrise.

In five days the rash had completely disappeared, and within ten days the sore had not only healed, but the induration was scarcely palpable.

CASE 3.-A case of malignant syphilis contracted in 1905, and in spite of almost continuous treatment, patient was admitted to the Lock Hospital with redness and swelling, and gummatous ulceration of the exterior and interior of the nose, ulceration of pharynx and palate, with a large perforation of the latter.

Eight days after patient had received an injection of 0.45 grm. the nose had resumed its normal size, the redness had almost vanished and the ulcers were healed; the discharge from both the nose and pharynx had ceased; naturally the hole in the palate had not diminished in

size.

The patient a fortnight later informed me that his friends scarcely knew him.

'J. E. R. McDonagh, F. R. C. S., London Practitioner, Nov., 1910.

CASE 4.-Another case of malignant syphilis similar to the one above, except that the patient had elephantiasis of his lower lip with extensive ulceration.

0.45 grm. was injected, and within 14 days the swelling had conpletely gone down and the ulcers cicatrised over.

CASE 5 was one of special interest owing to the fact that eye complications were known to supervene after using the arylarsonates. The patient besides having the usual symptoms of secondary syphilis had a bad iritis of the right eye.

After an injection of 0.45 grm. the photophobia had almost disappeared in 24 hours, and three days later nothing beyond a slight conjunctivitis was perceptible. The pupil was circular, reacted normally and there were no synechiæ.

CASE 6.-A case of congenital syphilis. The patient aged 15 years, under the care of Mr. Elmslie, received 0.3 grm. for severe gummatous ulceration of the left thigh and leg. The ulcers on the leg reached to the periosteum and bone. The patient had been treated for a long period with mercury without effect, and within ten days after injecting No. 606 the ulcers had healed.

I have had 20 cases under treatment; in only one was there albuminuria, which appeared a few days after the injection and did not last longer than 24 hours. Two cases had a localized toxic edema of one buttock, which quickly resolved under frequent applications of lotio plumbi.

Whether recurrences will appear or not cannot definitely be answered, since we have not been able to watch our patients a sufficiently long time; years must elapse before a definite statement can be made.

A few cases have been reported in which fresh symptoms arose, and cases have occurred early in the secondary period which did not respond to treatment -two of the latter I treated myself. (The symptoms have since disappeared.)

The reason for such was owing to the dose being too small; at least 0.45 to 0.6 grm. is required for the fresh cases, while 0.3 grm. suffices to heal up any late lesions, however severe and old they may be.

There are already several methods of preparing the drug for injection, but owing to the pain being so much less when the sodium hydrate is neutralised I now always proceed as follows:

Since the powder will not act except as a mono- or a bi-sodium salt, and since it is not stable in this form, the drug is sent hermetically sealed, to be prepared fresh just before use.

Series,

Place the powder in a glass mortar and add 1⁄2 c.c. of ethyl alcohol to every onetenth of a gramme of the powder used. Dissolve as far as possible and then add while stirring 10 c.c. of very hot water; rub well with the pestle until a clear yellow solution is obtained; then add slowly I c.c. of normal sodium hydrate solution (40 grms. to the litre) for every o'i grm. of the powder and mix well; colour red with three drops of a 1⁄2 per cent. alcoholic solution of phenolphthalein and titrate with normal acetic acid (60 grms. to the litre) until the red colour has completely disappeared. A fine yellow emulsion now remains. Finally, add a few drops of normal sodium hydrate until a faint rose tint returns and remains—so that the solution

is just alkaline. Inject half the quantity of the emulsion into each buttock; although the steps taken may be the same in every case, little hard lumps may form in the emulsion which block the needle during injection; the prevention of these lumps is best secured by dissolving the powder well in alcohol and seeing that a clear solution is obtained with the water before the sodium hydrate is added.

Owing to the disastrous results which were obtained with the arylarsonates, this new preparation has been received with a certain amount of fear and an undue amount of scepticism. Its non-toxicity is surely proved by healthy animals behaving indifferently to an injection, and that the toxic dose is only o'i grm. per kilo.; therefore a man would require between 6 and 7 grms., and the biggest dose so far given has not exceeded 0.7 grm.

There are certain people who show an idiosyncrasy to arsenic, and it is quite possible that an injection of No. 606 might produce alarming symptoms; many patients are by a single injection rendered over-sensitive to the drug, and such patients again might show toxic symptoms on repeating the dose.

Fortunately we have a means of testing this over-sensitiveness, or anaphylaxia, since either a conjunctival reaction after Calmette, a cutaneous reaction after Von Pisquet, and an intra-dermal reaction after Wolff-Eisner may be obtained with the solution used or what I always employ, a solution of arsacetin, 03 grm. in 3 c.c. of

, 1910

, Bol, 1, No.

water; patients giving a positive reaction should not receive an injection."

The Treatment of the Hookworm Disease. Lindeman gives the following treatment for hookworm disease: The patient should have nothing to eat from noon of the day previous to the administration day of the thymol. On this day and the day following, fat of any kind, milk, cream, butter, bacon, etc., should be avoided. Whiskey, beer, wine, and oils are absolutely interdicted, as all these can dissolve thymol. Early in the evening of the first day sufficient Epsom salts should be given for efficient purgation. It is important that the bowels should be well moved. Early the next day the dose of thymol decided on should be divided into two parts and given one hour apart. It is best administered in cachets triturated with equal parts of milksugar, and before using, the cachets should be well softened in water until they are of the consistency of a raw oyster. It is best to put the patient to bed, on the right side. The thymol should be retained for from two to five hours, unless distress or symptoms of intoxication occur. Epsom salts should then be used for flushing the bowels and expelling the drug. The following dosage as outlined by the State Board of Health of Florida is considered safe to use: Under five years of age, up to 8 grains; from five to ten years of age, 8 to 15 grains; from ten to fifteen years of age, 15 to 30 grains; from fifteen to twenty years of age, 30 to 45 grains; from twenty to sixty years of age, 45 to 60 grains; over sixty years of age, 45 grains. In determining the size of the dose the apparent age and the real weight of the child should be considered. The nauseating effects of Epsom salt can be considerably lessened if dissolved in the smallest quantity of warm water possible and swallowed; this to be then followed by a large quantity of any mild fluid, even water. The mixing thus takes place in the stomach instead of in the glass. The patient may begin to eat after the bowels are well moved on this day. It is best that they should eat sparingly and avoid distress from engorgement. The same precautions should be observed on this day regarding fats, oils, alcohol, etc. Once 'M. D. Lindeman, M. D., Jour. A. M. A., liv: 1910.