believed. He asked if one was warranted in sending such cases out without inoculating guinea-pig to test the virulence of the bacilli. There was no doubt in his mind but that all such cases with diphtheria bacilli in the nose, all clinical evidences of the disease having disappeared, were possible sources of danger. Culture should be taken from all children exposed to the disease; those showing the bacilli should be appropriately treated.

Epidemic Meningitis in Infants.-Levy, in Medizinsche Klinik, points out that the typical symptoms of acute onset, convulsions, and high fever, and the classical signs of rigidity of the neck and Kernig's sign do not usually appear in the meningitis of very young infants, excepting very late in the disease. Kernig's sign and rigidity of the neck are absent in from 50 per cent to 60 per cent of the cases under two years of age. Convulsions, which occur in so many infantile diseases, especially in spasmophilics, occur in young children with meningitis in only one-third of the cases. Intestinal irritation without fever and also inflammation of the entire respiratory tract often occur for weeks before some other definite symptom which indicates meningitis is found. Infants are especially liable to secondary infection of the lungs in meningitis, the true nature of which is thus often masked. With a few exceptions, almost all cases of meningitis in children of two years and under, Levy finds, have been treated for a variable length of time, even forty-five days, as cases of intestinal or pulmonary catarrh. Rigidity of the neck alone is a slight but fairly frequent accompaniment of these inflammations of the lung or intestine. A remittent type of fever is rather characteristic, the periods between the rises being short at first, and grow longer as the disease advances. There is often no febrile reaction at all. Levy has not found slowing of the pulse a characteristic feature, except in some forms of tuberculous meningitis. Symptoms referable to the central nervous system, such as the patellar reflex, etc., are, unfortunately, usually absent or doubtful. However, strabismus, usually fleeting, and pupillary inequalities are among the most constant signs of the disease. Hypersensitiveness, especially of the legs, is a cardinal symptom, as also are the pupillary dilatation from pain, on pinching the spine, and a reflex tremor of the whole body or of a group of muscles on sitting the child erect or moving its limbs. This tremor, however, usually presents itself during or after the fourth week of the disease. Highly important from the diagnostic viewpoint are altera

tions in sight or hearing, such as blindness or deafness, following an illness of uncertain nature. Subsequent to such an illness, otitis media, neuroretinitis, or iridochoroiditis invariably means meningitis. In infants, a widening of the fontanelles is of great diagnostic value, as showing increased tension of the cerebral fluid. This is often an early sign and a common condition in epidemic meningitis. Ventricular puncture is important in diagnosticating all cases showing increased tension of the cerebral fluid, as the cocci are often found here when they are absent in the spinal fluid. Lumbar puncture is essential; but as this means is not always available, and a bacteriological examination requires time, a provisional diagnosis at least should be made from the symptom complex, so that treatment by serum injection may not be delayed.

in

New Hysteric Symptoms.-Goldbladt, Muenchner Med. Wochenschrift, mentions two symptoms not, hitherto, emphasized, but which he has found in many individuals of the type usually dubbed "hysteric." One of these keynotes is subjective in nature, the patients complaining of a most disagreeable sensation of dryness in the mouth, sometimes in the throat. This symptom, which, so far as the author knows, finds no mention in the literature, has been the most frequent symptom complained of in the buccal region. It is often associated with globus, and in patients displaying the most complete and characteristic symptom-complex, it is seldom absent. Whether it is a matter of paresthesia-in the sense of a disturbance of sensorial powers or, possibly, a decrease in the secretion of saliva (sometimes observed in the hysteric), is not known. The subject, however, is worth further investigation. The second symptom-mention of which has not been found in hysteric literature, is a vaso-motor phenomenon capable of objective apperception. The flushed cheek of the hysteric patient has-in a great number of cases-an edematous appearance and, further, a somewhat bluish tint. If this sign is characteristically in evidence, the observer will receive the impression that the hysteric individual has applied a suitable stratum of bluish-rose face-power to the area mentioned. If, at first, it is not particularly noticeable, the symptom may be induced by means of some slight local irritation (gentle stroking, tapping) or by relating some sentimental figment of the imagination. This bluishrose, slight tumefaction localizes, as a rule, on the two cheeks; often, also, in the median line of the forehead; sometimes it appears over the whole face; rarely-in the severest attacks of

hysteria-it is one-sided. Possibly, it is just Possibly, it is just this vaso-motor phenomenon, associated with the peculiar expression of the face that lends a characteristic look to the patient, now and then permitting a diagnosis at the first glance. In neurasthenic and depressive states, this phenomenon has not been observed, though sometimes noted in non-hysteric, neurotic women during the menopause. It may be considered heterodox to mention, nowadays-when the old-time hysteric stigmata are thrown aside these new ones, but 200 instances where these phenomena were present, are on the author's records, and are considered valuable characteristic and differential indications of protean and still unexplained hysteria.

Significance of Abdominal Pain.-Harsha, in the Lancet-Clinic, cites the general law that diseased viscera cause pain at or near their various sites; but declares there are many exceptions, which lend importance to the reflex or referred pains. This applies to both spontaneous and elicited forms. In most visceral lesions there is a disturbance manifested variously by pain, tenderness, hyperesthesia or muscular rigidity of certain areas of the external or protective portions of the body. Hilton ("Rest and Pain") called attention clinically to the protective function of the muscles in joint disease; and later the mechanism has been shown to be a reflex by other investigators. In most abdominal lesions the pain is felt in the abdomen whether referred through the spinal nerves or directly from the viscera. It is well known that pain in the back is also marked in many such lesions. In ulcer of the stomach or duodenum and in gall-bladder disease the pain extends to the back for the most part at a level or somewhat above the level of the diseased organ. In pelvic disease the pain in the back is also in evidence in the sacral region. In retroperitoneal abscess, perineal or appendical, or in glandular involvement we also find the greater complain of pain in the back; and especially in the metastatic glandular involvement from testicular cancer.

Pottenger, of California, has recently shown the motor reflex in diseases of the lung and pleura. Sensory reflex is also recognized in similar conditions. This exteriorization of pain, hyperesthesia, or rigidity as a reflex may be of great aid in diagnosis, or may mislead one of the fact of the reflex is ignored or the nerve supply not understood. Clinically increased importance attaches to the reflexes, both dorsal and abdominal, as aids to more accurate diagnosis.

Reasoning from the demonstration of Haller,

Harvey, Lenander and others, that the viscera are in health insensitive to ordinary irritative stimuli, and incapable of accurate localization of painful sensations; and from the fact of the exalted sensory and motor function of the protective portions of the body, e.g., the abdominal wall, Mackenzie ("Symptoms and Their Interpretation") ascribes nearly all the pain in visceral disease to the reflexes; and ascribes the tendency in many visceral lesions to produce pain referred to the apigastrium or other median portion of the abdomen, to the fact that the spinal nerves abundant in skin, muscular and preperitoneal fascial layers of the abdomen have their termini toward the middle line.

The involvement of the solar plexus, of course, accounts in a general way for the more central abdominal pain in various visceral lesions.

On the theory that the pain in viscereal disease is largely reflex we can best account for the enlarged area of pain, rigidity, tenderness and hyperesthesia occurring in fulminant cases.

Sherrington ("Integrative Action of the Nervous System") says: "That in spinal reflexes, increase of the intensity of the exciting stimulus causes increase in the number of motor neurons excited is clearly shown by the wider musculature seen to be engaged as the reflex irradiates under intenser stimulation."

Probably the most severe attacks of abdominal pain are due to the various acute perforations, e.g., intestinal, gall-bladder or tubal. These are associated with wide areas of pain, hyperesthesia and muscular rigidity; in fact, the whole abdomen is seemingly involved while the lesion may be limited to a square inch or two in ex

tent.

In cases with broad radiation of pain the behavior of the reflexes under anesthetics or analgesics may aid us in locating the site of disease, as clinical experience seems to show that the marginal pains are the first to disappear under narcotic remedies.

Sherrington (page 80, as above) says: "Reflexes are nevertheless among the earliest reactions to alter or fail under asphyxal conditions," and again, "the dosage of chloroform or ether required to depress and abolish a nerve trunk conduction is much greater than is required to depress or abolish the cerebrospinal reflexes."

Dr. J. H. McKeay, in his work on the medical treatment of gall-stones (quoted by Mackenzie), refers to this observation and gives his own experience with chloroform during an attack of gall-stone colic. "Give a whiff of chloroform, not enough to produce unconsciousness, and the distant referred pains disappear, their mode of

disappearance being very interesting to any one cool enough to observe it, and there remains only subdued pain in the region of the right hypochondrium, a spot so small that one could cover it with the tips of one or two fingers."

Ocular Symptoms in Goitre.-Victor Ray, in the Lancet-Clinic, states that the important and characteristic ocular symptoms are, first, the exophthalmos, which is most frequently bilateral, sometimes the protrusion, being slight, in other cases so great that the lids cannot close. The exophthalmos may be absent altogether or confined to one eye. As to the cause of the exophthalmos, it is due to the chronic engorgement of the retrobulbar orbital vessels, which undergo to a greater or less degree hyperplastic changes, for even after treatment which may improve or relieve the general symptoms, the exophthalmos may persist. Griffith (Ophthalmic Review, No. 5, p. 149), out of 32 cases, reports the presence of bilateral exophthalmos 25 times, unilateral right-sided 4 times and left-sided 3 times.

The next important symptom is the Von Graefe symptom, in which the upper lid does not follow the motion downward of the eyeball, and appears to be held back by a spasm of the lid. The frequency of this symptom varies greatly, as reported by different individuals, as low as 14 per cent in the cases by S. West (British Medical Journal, May, 1886) to 56 per cent (A. Lewen, Zur Kasuistik d. Morbus Basedowii, inaugural dissertation, Berlin, July, 1886). The Graefe symptom is nearly always bilateral. The explanation of the cause of this symptom is to a certain extent as obscure as that of the disease

Various, theories have been advanced. Formerly it was supposed to be due to a stimulation of the sympathetic producing a hypertonus of Muller's fibers. Another that it was due to a lesion of the vasomotor centers affecting the thyroid gland and the loose connective tissue of the orbit, at the same time, affecting the vagus. The Stellwag symptom is the next one of importance. This is the infrequent winking, sometimes not more than two or three times in a minute..

Other symptoms of lesser importance are the Moebius symptom, that of difficult convergence, and the Gifford symptom, the difficulty of everything the upper lid. Pulsation of the retinal

vessels is occasionally found.

The treatment. of ocular complications depends largely on the degree of exophthalmoş. If the proptosis is excessive, and the lids do not adequately close the palpebral fissure, particularly during sleep, desiccation of the cornea with ul

ceration will take place; bandaging the eyes may be used, together with bland ointments. If this is not sufficient, an operation for permanently narrowing the palpebral opening will be necessary, thus protecting the cornea as well as conjunetiya.

Bladder Hernia.-Coughlin, in the Journal of the Missouri State Medical Society, says that to make a diagnosis of bladder hernia before operation one must be on the watch in every case of hernia for symptoms or signs of bladder hernia. If we would always keep in mind the fact that the bladder is liable to be found in the hernia and make investigation, no doubt we would in a great majority of the cases be able to make the diagnosis before the operation.

In all hernia patients, then, inquiry should be made regarding urinary symptoms. The hernia might be palpated before, during and after micturition. The patient might be made to urinate while standing and then immediately to lie on the sound side or on the back so as to empty a possible diverticulum of the bladder, and then again made to urinate. The cystoscope is sometimes an aid to diagnosis and should be used in all cases. Karewski made the diagnosis in two of five cases with it. Pressure should be made on the tumor in order to see if this causes a desire to urinate. The girth of the tumor should be taken just before and after urination. A less girth afterward may be taken as a positive sign. Percussion over the tumor gives a flat note, but so it does over an omental hernia.

If the hernia be strangulated the symptoms of retention, tenesmus, or bloody urine, as in my case, ought to warn the surgeon. Symptoms of incomplete bowel obstruction make one think of Richter's hernia or hernia of omentum. Such symptoms, however, are found in strangulated bladder hernia. A rectal or vaginal examination shows great tenderness in the region of the bladder.

Roth advocated filling the bladder with fluid. He noted that more force was required to fill the bladder if a hernia existed. The author believes that the injection of fluid might aid in the diagnosis if one observed that the injection increased the size of the tumor. A sound in the bladder may sometimes be so manipulated as to bring its tip into the herniated part and there may be palpated through the skin.

In about 90 per cent of all cases the diagnosis is made at operation and in nearly all these the first sign is gush of urine when the bladder is eut. In many cases the surgeon thinks it the sac; in others a mass of fat, and cuts it. Some

times it is wounded in freeing the posterior wall of the sac, or again it is taken for a hydrocele of the cord.

The

Diagnosis of Rickets. Barbarin, in La Clinique, discusses the typical signs and symptoms of rickets. He considers that diagnosis may be difficult when the clinical picture is incomplete and only one or two symptoms are manifested. A single symptom may be so exaggerated as to suggest some other disease. Hydrocephalus may be mistaken for rickets in its early days; it is found that when the large fontanelle is auscultated there is a "souffle" in the rachitic case which is not heard in the hydrocephalic. hydrocephalic head develops as a whole, whereas in rickets the enlargement is confined to frontal and occipital regions with depressions between the bones. The syphilitic cranium is natiform and does not resemble the bossy head of rickets; but the writer has seen a typical natiform head with all the physical signs of rickets in a case which improved upon antirachitic treatment. It is rare to find several of the intercostal nodules joining together to form a mass resembling a tuberculous osteitis of the costal region. Occasionally the deformity of the thorax will suggest Pott's disease in the upper dorsal vertebrae. The absence of curvature of the spine differentiates the condition, but rickety kyphosis has often been mistaken for Pott's disease, and is most readily distinguished by examining for rigidity; the rachitic spine is flexible. Curvature of the neck of the femur will suggest coxa vara. When unilateral it may cause a slight limp and some compensatory scoliosis; when bilateral it may simulate double congenital luxation of the hip. The diagnosis can only be arrived at by the aid of radiography. The head of the bone cannot be felt, and the gait is characteristic of luxation, etc. Rachitic hypertrophy of the condyles of the lower end of the femur or of the wrist may resemble tuberculous osteitis, unless the perfect mobility and absence of pain and muscular atrophy are remarked. Flat-foot is very commonly associated with curved tibiae. All the conditions mentioned are purely rachitic, and may be corrected by medical treatment.

A New Sign of Inflammation of the Meninges. -Signorelli describes the so-called retromandibular tender point as a constant sign of meningitis. This point is located behind the superior extremity of the inferior maxilla, below the lobule of the ear, and in front of the mastoid process. In healthy individuals this point is sensitive, but

in cases of meningitis pressure with the index finger elicits extreme pain and provokes contractions of the facial muscles: it is apparently the trunk of the facial nerve which is sensitive. The sign is present throughout the attack. It often precedes the stiffness of the neck and the Kernig sign. In tuberculous meningitis the muscular contractions, after pressure at this point, occur even when the patient is paralyzed and comatose.

Treatment of Skin Diseases by Colon Lavation. -Mantle says there is ample proof that, in some individuals, ingested toxines absorbed in the alimentary canal show the chief evidence of that absorption by changes in the skin. The author proposes the following treatment of such cases, which consists in colon lavation: An alkaline sulphur water is generally used both for the intestinal douche and for the immersion bath which follows it. The object of the internal douche is to wash away old fecal matter and mucus from the colon and to give the mucus membrane an antiseptic dressing. This is done in the following way: A long rubber tube after being sterilized is passed into the sigmoid and is attached to a hydrostatic douche, when from twenty to forty. ounces of sulphur water at a temperature of 105 degrees F. pass into the colon at a pressure of two feet, the patient lying first on the right side, then on the back, and lastly on the left side during the operation. This is repeated and the ejecta after each douche are carefully examined and reported upon by a skilled attendant. Antiperistalsis of the colon normally exists, and is an important factor in this treatment, enabling rectal injections to reach the ascending colon and caecum when diseased. A warm immersion bath of sulphur water follows the internal douche, and when in this bath a hot douche at a higher temperature plays upon the wall of the abdomen under water from a large nozzle with fine perforations, and is chiefly directed over the site of the colon. The immersion bath not only opens out the peripheral circulation, and thus relieves any congestion of the viscera which may exist, but is beneficial to the skin and nervous manifestations the result of autointoxication.

Coffee and Blood Pressure.-Elsuer, in the American Journal of the Medical Sciences, declares that coffee raises blood pressure because of the caffeine which it holds, and this rise is associated with increased rapidity of the heart's action. It makes the heart irritable, it increases the power of the heart's contractions, it places an extra load upon the kidneys, increasing the urine flow, and the solids of the urine are increased by overtaxing its secreting cells. Because of these effects I have for some time held that men beyond fifty who get insufficient exercise or are brain workers, and children before puberty, cannot with safety to themselves drink. coffee. There is something in the coffee bean besides the caffeine, of which it can be freed, which also acts as a healthful stimulant to brain and other organs and makes it a valuable article of diet. A patented process is now being used in Germany by which the coffee bean is freed of 90 per cent of its caffeine. This coffee has been largely used abroad during the past two years with great satisfaction. There is scarcely a health resort in Germany which is not largely substituting this coffee for the ordinary coffee of commerce. The taste of the coffee is not materially changed from that of ordinary coffee, the effect, however, upon the heart and blood vessels is decidedly different. Patients who have never been able to take coffee, whose circulation, particularly the heart, has been unfavorably affected are able to take it when freed of its caffeine with impunity. During the past year the author has given it a fair trial and is thoroughly convinced of its value and the desirability of using it in all cases of hypertension, arteriosclerosis, and irritable heart; indeed, he believes that it is the ideal coffee for all brain workers or those of sedentary habits after the age of fifty. Blood pressure is not increased by its use, nor is there palpitation, or annoying systolic force.

X-Ray Diagnosis of Syphilis.-Skinner, in the Interstate Medical Journal, says the radiographic diagnosis of acquired syphilis will depend upon the amount of osteal involvement. We usually

look for these tertiary complications in the tubular bones of the legs and arms and the plates of the skull. The syphilitic invasion of the nose and palate, because of their anatomical locations, do not lend themselves to x-ray demonstration. The latter are usually so evident by inspection and palpation that the x-ray offers nothing of value.

The syphilitic attack upon periosteum primarily displays itself radiographically by a cloudy shadow of the periosteal area, which is broader than normal. As the process increases we note a more distinct outline of the periosteum, with flecks of ossifying centres. If the process does not recede, we find that this ossification of the exudate resembles a layer of plaster upon the normal contour of the bone. If the cortex has become involved, without the formation of distinct areas of gummatous degeneration, this plaster process casts dense shadows, showing the osteosclerosis of cortical and periosteal areas. Where the cortex beneath an involved periosteum develops gummata, these gummata will appear as lighter spots surrounded by a darker zone of inflammatory exudate. The changes described in this paragraph are usually displayed in the tubular bones of the leg and forearm. Friedrich (1) states that a characteristic roentgen finding in syphilis is the combination of a gummatous periostitis and ostitis, with an ossifying periostitis and ostitis; an osteoporosis plus an osteoplastic

process.

Extirpation of Cancerous Bladder.-Petrow, in Deutsche Zeitschrift fur Chirurgerie, says that so far as carcinoma is concerned the urinary bladder belongs in the same class with the eyeball, the testicle, and the parotid gland, in which organs this disease remains localized for a long time and only late gives metastasis. Therefore the removal of the bladder promises lasting freedom from the disease. The chief difficulty in the way of this operation is to provide proper exit for the urine. It is this difficulty which makes surgeons so loath to undertake removal of the bladder. However, in wide-spread carci