their use except as an occasional remedy administered under medical supervision.

Trional, like sulphonal, may disorganize the kidneys, and a similar result may be anticipated in other hypnotics that produce a rash.

In cases of phenacetin poisoning, the urine gives a positive reaction with Fehling's solution, although it contains no sugar.

As regards drugs, then, we are enabled to arrive at two good general principles, namely:

1. To suspect danger to kidneys and other excretory organs in any drug that produces a rash.

2. Never to give a protracted course of a rash-producing drug.

Arsenic produces multiple rashes. It also irritates the kidneys, and cases have been reported where chronic kidney disease has followed its prolonged administration. Yet arsenic is often given, especially in skin troubles, for months and even for years together. In this case, "Out of sight out of mind" appears to be true of that most delicate and muchabused excreting organ, the kidney.

The specific virus of the exanthems is thrown off from the body by the excretory organs, inflicting upon the latter more or less damage. The fact of the passage of the virus is shown by the subsequent infectiousness of the malady (i. e., in all, or nearly all, communicable fevers.)

In 1897 I wrote of scarlet fever: "The question is, through what particular channels of exit do the active germs (presumably present) escape? If through the kidney and bowel discharges, then it is tolerably certain that effective measures are not taken in one case out of a hundred, even in our best ordered fever hospitals to disinfect these evacuations. The only attempt at systematic disinfection of scarlet fever cases appears to be directed to the skin, the clothing, and other objects that have been in contact with the skin. Upon logical grounds there seems to be good reason for regarding with grave suspicion all excreta from a scarlet fever patient."*

I then proceeded to discuss the probable excretion of the pathogenic bacteria of typhoid fever, and of other specific fevers by the skin, kidneys, and other excretory channels. That was in 1890, and when the disinfection of urine in typhoid fever was, I believe, unknown, although now in 1904 it is a routine practice in the metropolitan infectious hospitals. In 1897 the disinfection of urine and all other excretions in specific infectious fevers was specifically suggested by me as desirable upon grounds arrived at by pure reasoning founded upon the facts of gen-. eral excretory irritation. At the later date, I think I am right in stating that disinfection of typhoid urine was not in vogue in the London fever hospitals.

On

The law of excretory irritation has not been generally accepted under that title amongst British medical workers. the other hand, it has never been upset by adverse criticisms. One gentleman at a medical society quoted a passage from Trousseau to the effect that a poison in the body might affect various outlets, and appeared to think in that way my conclusions had been anticipated by those of the illustrious French professor. So far from that, occasional references of a similar kind may be found scattered throughout the whole range of medical literature from Galen onwards. To speak vaguely of the elimination of a virus from the body, however, is a different matter from demonstrating the principle of the inflammatory action upon all excretory organs by blood-borne internal irritants, whether the latter be of a chemical, an auto-genetic, or a bacterial origin. It is certain that, nowadays, the principle is widely accepted by medical authorities, although the name of "excretory irritation" is not added. Under different guises my original theory has been arrived at by various continental and English writers during recent years.

The BRIEF Comes promptly every month. As father is an editor, we have magazines and papers galore-none, however, which is read with more interest than the BRIEF -always something of interest and value for every member of the family.-GUSTAV E. HENCKEN, M. D., Ravenswood Station, Chicago.

[Written for the MEDICAL BRIEF.]

Small-Pox.

BY FREDERICK H. DILLINGHAM, M. D., Adjunct Professor of Dermatology New York Polyclinic; Late Assistant Sanitary Superintendent New York Health Department; Visiting Physician St. Joseph's Hospital; Fellow of the Academy of Medicine; Member of the County Medical Society; Medical Association of Greater New York, Etc., Etc. New York City.

Small-pox is a subject of great interest to the medical profession, on account of the numerous types which have been prevalent over the United States for some years past, and the fact that, as a rule, the first cases have not been correctly diagnosed, and the true nature of the disease recognized only after it had made considerable headway.

During the twenty-two years that I was connected with the Department of Health in the city of New York, I saw nearly fifteen hundred cases of small-pox, and probably as many more which were incorrectly reported as such, and I can truly say it is often one of the most difficult diseases we have to diagnose, and sometimes a positive diagnosis is impossible.

Small-pox is one of the most contagious of the exanthemata, and few persons exposed to the disease escape unless protected by a previous attack or vaccination. The disease is common to all ages, and the contagium is present in the exhalations, secretions, and especially in the crusts. There is no danger of contagion during the period of incubation, before the prodromal symptoms appear. The period of incubation is usually about two weeks, although I have seen it vary from seven to twenty-one days.

Invasion is usually marked by chill, often convulsions in children, severe frontal headache, and pains in the back and limbs, and, as a rule, there is high temperature. The prodromal symptoms, however, will not always give an indication of the severity of the disease, especially in the milder cases. A rash resembling that of scarlet fever or measles sometimes appears before the true eruption, and is most frequently seen in the inguinal region and in the axillæ. Another form is the hemorrhagic, in which

petechiæ appear over the whole body, even on the mucous membranes, and the patient may die before the appearance of the true eruption, in which case a correct diagnosis is often not made until other members of the family are attacked with small-pox.

In a typical case of small-pox the eruption appears on the third or fourth day as small red spots, which, in a few hours, become papular, elevated, and "shotty" to the touch, and are usually seen first on the mucous membrane of the mouth, then on the forehead and wrists, and extend gradually over the whole body.

With the appearance of the eruption the premonitory symptoms usually disappear, although they may continue for several days. The papules increase in size, and become vesicles with clear contents on the fifth or sixth day, often become umbilicated, and on the eighth day contents are yellowish in color, the umbilication disappears, and the form becomes globular. The pustules may dry quickly and become crusts. This process takes place first on the face, and follows the course of the eruption. The pustulation, fever, and general symptoms return, but subside usually after two or three days, although they may continue longer. In confluent cases, symptoms are more severe, and the lesions run together and coalesce. In mild or modified cases there may be no prodromal symptoms, and the eruption may be the first thing noticed; the lesions may be very small and develop quickly, some not advancing beyond the papular stage. Again, they may be superficial and become vesicular during the first twenty-four hours, and sometimes are seen first on the body instead of the face. I have seen a case where there were only six lesions on the body, and they entirely disappeared in seven days.

A few years ago the authorities all maintained that the lesions in small-pox never came out in successive crops, but I have seen a number of cases where papules, vesicles, pustules, and crusts were present in the same area.

The disease most likely to be confused with small-pox is chicken-pox. In typical cases there should be no difficulty in making the diagnosis, but those of the irreg ular type often present great difficulty

even to those who have had a large experi ence. There is no symptom or character of the lesion that is found in chicken-pox that I have not seen in some degree in small-pox, and it is necessary to carefully consider the early symptoms and character of the lesions. Some claim that chicken-pox does not occur in adults, but I have seen many such cases.

In making a diagnosis, the following points will be of value, although in the irregular cases the symptoms vary, and none of them can be depended upon. The invasion is more severe in small-pox, and lasts three or four days, while the eruption appears on the first day in chickenpox, and there is no secondary fever. In some cases of small-pox the invasion may be slight or not noticed, and the secondary fever absent. The temperature in small-pox usually falls when the eruption appears, while it increases in chicken-pox during its development. In small-pox the eruption appears first on the mucous membrane of the mouth, then on the forehead, and wrists, while in chicken-pox it is first seen on the shoulders and chest, although it may be present in the mouth.

In small-pox the lesions are more uniform and deeply seated, and commence as small papules, not usually becoming vesicles before the second day, while in chicken-pox they appear as maculæ, which develop into vesicles in a few hours, and are very seldom shot-like, but superficial, flat, and of irregular shape. The vesicles usually have a firm base in small-pox, while they are superficial, and can be easily brushed off in chicken-pox. In small-pox the eruption usually follows a regular course over the body, and does not appear in successive crops as in chicken-pox. Umbilication may be seen in chicken-pox, but is not as general as in small-pox. The pustules in small-pox keep their form well for several days instead of becoming flattened and breaking down, as in chicken-pox. The secretion in chicken-pox is mostly transparent. The duration of an attack of chicken-pox is much shorter, and there are few scars.

In measles, the catarrhal symptoms are a great aid in the diagnosis, the temperature gradually increases, and reaches its height while the eruption is appearing over the body, but there is not the rapid

fall seen in small-pox. The eruption spreads very rapidly, and the lesions are larger, crescentic, and more superficial, without the "shotty" character, and never become vesicles or pustules.

The hemorrhagic form is sometimes mistaken for scarlet fever, but the constitutional symptoms are more severe, and the eruption does not disappear on pressure, and is of a more intense red color. The absence of the crusts, the condition of the tongue and throat, hemorrhages of the conjunctiva, should exclude scarlet fever. In syphilis, the history of the case and character of the lesions should enable one to make a diagnosis. I have seen persons suffering at the same time with smallpox and scarlet fever, small-pox and measles, and small-pox and syphilis and it should be remembered that this may occur.

Cold

Treatment.-All carpets and furniture should be removed, and the room should be well ventilated. Cleanliness of the patient is very important, and the linen should be frequently changed. Everything that has been in contact with the patient must be disinfected. The treatment is mainly symptomatic. It is often necessary to give opium or one of the cold tar series to relieve the pain in the beginning. The diet must be light during the early stage of the disease, and it is well to rely upon milk and broths. drinks may be freely given. The fever may be reduced by cold sponging or by wet pack. The lesions should be protected from the light, and lint soaked in a weak carbolic or bichloride solution can be applied to the face and hands. The body should be anointed with vaseline or some oil which relieves the itching, keeps the crusts moist, and prevents desquamation from flying in the air. If there are many lesions on the scalp, the hair should be cut short. Particular attention should be paid to the condition of the eyes, mouth, throat and nose, and they should be cleaned and washed with an antiseptic solution several times a day. The patient must not be discharged until all the pocks have been removed, and the desquamation has ceased.

148 West Eighty-Fifth Street.

A merry Christmas and happy New Year to all.

[Written for the MEDICAL BRIEF.]

The Growth of the Science of Medicine and the Progress of Medical Education in the United States.

BY JOHN C. LE GRANDE, M. D., Professor of Obstetrics Birmingham Medical College: Editor "The Alabama Medical Journal;" Ex-Vice-President of the American Medical Association; Ex-President of the Medical Association of the State of Alabama; Ex-President of Tri-State Society of Tennessee, Georgia and Alabama. Birmingham, Ala.

When we review the work of the past centuries in the general scientific world, it is not strange that we find that the science of medicine has kept equal pace, and has, as the other sciences, passed through the formative and chrysalis state to a condition of steady growth, whereby it has developed into a fully recognized and distinct science. That it should have remained so long as charlatanry, and that the physician should have been regarded through that period as a quack or "hoodoo-man" can be readily explained in the light of our present knowledge.

The science of medicine embraces the total knowledge of all the different branches of science, and the art of practicing medicine is the art of applying the principles of all scientific methods for the purpose of relieving suffering humanity.

With this definition of the medical science, we can see that our present system of medicine has developed by a process of evolution and natural growth, progressing methodically with the development of the composite sciences, and as knowledge grows, as all nature, by the law of occasion, and necessity, it happens that we find the sciences in any period in the same condition as the existing state of society. In developing history of the medical science, we find that this relation has always been invariable, and we can determine the condition of medicine at any past century by knowing the state of society at that time.

The beginning of the nineteenth century seems to have been the birth of the renaissance of science in Europe. The way having been prepared by the five former centuries of intellectual culture and development of the classical education; and, as science and liberal education bear

the same relation to each other as fact and philosophy, we find that as one grew, the other expanded, and as one expanded the other grew. With this relation and interdependence, a little philosophy and a few facts found in the earlier part of the nineteenth century, have, by the process of induction and deduction, so expanded until the scientific method has invaded every branch of knowledge and every process of life. We no longer act by instinct, but by reason; no longer live in darkness, but in truth.

The use of medicine or remedies had its birth from a condition of necessity. The fact that the human being became very early cognizant that he was mortal, that not only must he die, but that he was subject to many diseased conditions which were curable, made him very early investigate the causes of death and disease, and to devise means for their prevention. As we trace the history of medicine until it became a science, we find that as other things produced by conditions of necessity, it was subjected to some trying orIdeals, and some very bad practices following the laws, causes and progress of society at any period.

The first historical champion of its cause we find in Hippocrates, who flourished about 500 B. C.; after him came Galen, who probably pursued the same course, and used the same remedies, which consisted of a few botanical compounds, and some mineral alkalies; in the fourth century, A. D., we find hospitals established, and the science of sanitation founded. About this period one of the great masters died, who, during his life had promised to leave to his pupils a volume containing all the secrets that pertained to medicine. After his death the much coveted, large and beautifully bound volume was found, whose size indicated much untold knowledge, and many unknown secrets. On being opened, the following words were found: "The whole secret of medicine consists in keeping the feet warm, the head cool, and purging." Such was the condition of medicine at that time.

At the middle of the fourteenth century we find the bubonic plague raging in Europe, which the faculty of Leipzig attributed to effluvia from the existing vol

canoes. It was from this cause that Venice had three officers appointed to guard the public health. During the middle of the fifteenth century, there was caused to be appointed by the imperial diet physicians in every part of the German empire, whose duty was the guarding of public health. In the sixteenth century we find Paré, the father of French surgery, and Harvey, the demonstrator of the circulation of the blood, at work in France and in England. At the middle of the eighteenth century there was not a privy closet in Madrid-the excretory matter was thrown at night into the streets, to be removed the next day by public scavengers; the general opinion of the physicians and officers of sanitation was that it would purify the atmosphere.

The King of Spain then gave an edict for the establishment of closets, which was strenuously opposed by both laymen and physicians. They yielded, however, with the permission to put them near the kitchens, in order to purify the food by the emanations from the closets. Such was the condition of the science of medicine and the state of society in certain parts of Europe at that time.

In the middle of the eighteenth century, Velpeau, dressed in rags, and amid the derision of his companions, was studying anatomy. In 1776, Jenner made use of the process of vaccination. At the beginning of the nineteenth century there were no microscopes which could be used for investigating tissue. A volume of "Clinical Medicine," published in 1806, has no mention of the anatomical changes in heart disease. In 1808, Corvisart explained the uses of percussion in diagnosticating disease. Laennec, in 1819, described the stethoscope, thus making use of invaluable instrument in the termining changes in closed cavities. In 1827, Bright laid the foundation for investigating changes in the kidney by urinary changes. Latour, in 1837, analyzed and explained the causes of putrefaction, and thereby paved the way for Lister's work thirty years later. In 1847, Leedy discovered the trichinis spiralis. Anesthesia came into use about the middle of the century, which completely revolutionized the science of surgery. Virchow, in 1860, announced his great cellular theory, which has made the

the

study of medicine a study of science. Oil immersion lenses had now become perfected, and made the causes of many diseases known, immediately following which Pasteur discovered the cause and cure of rabies, making the beginning of serum therapy. The bacillus of malignant edema was discovered, in 1875, by Pasteur; in 1880, the bacillus tuberculosis, by Koch, the bacillus diphtheriticus by Klebs. The bacillus typhosus by Eberth. The tetanus bacillus by Nicolaier. The pneumococcus, by Frankel, in 1884. The cholera vibrione, by Koch.

Several years later, the plasmodium of malaria, by Laneran. In 1894, the bacillus of plague, by Kitasato. Serum-therapy now came into use, which has robbed many of the infectious diseases of their terrors.

This was followed by the discovery of the cause and prevention of yellow fever. Then came the investigation of the mosquito as an intermedial host in the transmission of the organisms of malarial and yellow fevers. Along with this came the increasing number of discoveries with the Roentgen rays. We make mention of these merely as epochs showing some of the steps of progression, by which medicine has become a science. In surgery the steps of improvement have been equally noticeable, and it has been lifted from a simple trade of a barber to an exact, perfected, and brilliant science. Such names as Park, Velpeau, Lister, McDowell, Sims, Tate, Emmett, and many others, adorn the pages of its history.

The territorial growth of the science of medicine and medical education has been co-extensive with its intrinsic growth. Beginning in Europe, following civilization westward, it first met the United States in the Eastern States. Here it was confined a long time, because the pioneers of the country were busy for a century or more with questions not more vital, but more prominent

At the beginning of the nineteenth century we find the science with a fairly strong foothold. At this time there were four medical schools in this country, and the nucleus of the American profession was formed.. The profession, however, had not united themselves into a body, nor had the legislatures of the