have been inked, the lines they show in the impression will be narrower than when the ink has extended further down the sides of the ridges. It is only by taking into consideration the general and special aspects presented by the two prints and studying them in connection with the structure of the skin that the factors can be determined. The main features of the ridges and furrows are not distorted or altered in their directions by varying pressure, because in consequence of the difference in consistency which exists between the surface layers of the skin and the subcutaneous tissues the pressure is distributed and equalized in all directions. The expert who is called upon to determine the question of identity or non-identity from casual prints has frequently a difficult problem to solve, upon which he must bring to bear his knowledge of the anatomy and physiology of the finger as well as the information derived from his observations of the prints in order to enable him to arrive at his conclusion. Should he embody photographic enlargements of the impressions in his study he will find it desirable to use positives made on glass in his investigation.

The classification of finger impressions is chiefly of interest to those who have to arrange large collections. It has been elaborated with much care by Mr. Francis Galton and the staff of the Bengal police into a very complete system, of which only the outlines can be given in this monograph. For this purpose the arches are classed with the loops and the composites with the whorls, so that only two divisions of patterns have to be dealt with. The different combinations possible of these two classes on each pair of digits, beginning with the right thumb and forefinger, are then taken into consideration. Under this scheme there are four possible combinations on each pair of digits, which may be represented thus

LL WL LW WW

using the laitial L and W for loops and whorls, respectively. The five pairs of digits give individually and collectively with one another one thousand and twen

ty-four possible combinations, which form the primary divisions of the classification. The size of the groups will be most irregular as regards the number of sets of prints in each, but as the various forms bearing the impressions of different persons' fingers are kept in portfolios a larger or smaller number of groups can be placed together, much after the plan of a dictionary or encyclopedia, covering several volumes, where the size of the volume is the regulating factor. The actual formula of each pair of digits is written in the form of a fraction, of which the upper letter denotes the pattern of the first digit of the pair and the lower letter that of the second digit, thus the right thumb and forefinger bearing respectively a loop and a whorl is indicated as 1, and a complete formula might be written as follows: 1 lw lw WITTW

W

As the number one thousand and twentyfour is the square of thirty-two, all the combinations of the upper letters would be represented in a horizontal row of thirty-two small squares, and those of the lower letters in a vertical row of thirtytwo squares, placed at a right angle to the former row. Constructing a large square with one thousand and twenty-four compartments of chess-board-like appearance from these and other rows, each compartment would be accurately defined by the intersection of any of the horizontal lines with any of the vertical lines, and it is possible to assign to each of the one thousand and twenty four combinations represented by the compartments definite numbers corresponding to their places in the horizontal and vertical rows. This is done by considering the whorl division only, and assigning a serial number to each whorl according to the position it occupies in the finger formula. A whorl on either digit of the fifth pair bears the value one, a whorl on the fourth pair is two, on the third pair is four, on the second pair is eight, and on the first pair is sixteen. Taking the formula already given for the ten digits of the hands, it might be written according to the values of the letters composing it thus,

Totaling up the values of the rows, the upper row equals five, while the lower row is seventeen, the fraction five-seventeenths would indicate the compartment at the place of intersection of the fifth horizontal row with the seventeenth vertical row, as the definite position in the classification of a form bearing the above value, supposing the respective rows were numbered from 0-31. A finger formula composed entirely of loops would occupy the first place or upper left corner compartment of the chess board and would be designated 0, both horizontally and vertically. By writing out the formula and summing it up for the finger impressions of each person, the exact place he occupies in the primary classification is obtained. Secondary classifications are obtained from the particulars displayed by individual digits, such as the presence of an arch on the fore-finger; the slope of a loop, and the number of the ridges between the outer and inner terminuses; the deposition of the ridges below the deltas in a whorl, the special form of a composite, and the like.

[Written for the MEDICAL BRIEF.] Sterility in American Women.

BY A. BROTHERS, B. S., M. D., Adjunct Professor of Gynecology to the New York Post-Graduate Medical School and Hospital; Visiting Gynecologist to Beth-Israel Hospital; Fellow of Academy of Medicine; Member of the County Society, Obstetrical Society, Eastern Medical Society, County Medical Association, Harlem Medical Association, Society Alumni of Bellevue Hospital, Physicians' Mutual Aid Association. New York City.

Owing to the institutions of this country, with the opportunities for education and freedom of movement, the American woman is recognized to be intellectually the superior of many of her sisters across the ocean. This advanced position is not without faulty consequences, and these faulty consequences include, among others, a tendency, or rather disinclination, toward having large familes. As we descend in the scale of education among women, we find that this lack of desire to bear children becomes less and less marked, but even among the ignorant classes there is a distinct difference in this regard be

tween the women of various nationalities and religious beliefs.

The modern woman of today, like her educated sisters abroad, aims at having a small family. Perhaps placing the average of three children to a family would approximately express the truth in regard to our wealthy and cultured women of today. Besides the native women our country includes among its inhabitants a large population which has migrated to our shores principally from the older European nations, and which represents the ignorant or peasant classes. Among these women it is safe to say that a family of six children will represent a low general average to a family; in other words, roughly speaking, the number of children in a purely American family is one-half that which we find in the families of our immigrants. What are the principal reasons for this vast difference in procreation among women with the same anatomical and physiological qualities?

1. The majority of our foreign women are poor, intensely so, and from this circumstance are restricted rigidly to home life, which in itself is conducive to the rearing of families.

2. We find religion more scrupulously observed and believed in the lower we descend in the scale of humanity. Among certain religions, particularly the Roman Catholic and the Jewish, feticide is recognized as a crime in the eyes of the church, therefore, criminal abortions do not receive the complaisant sanction that they do among ladies and classes with lesser religious scruples. Among Jewish women particularly the prevention of conception is rarely practiced, even among the poorest, by the woman herself. The male, on the other hand, frequently may make use of such procedures within certain limits. The orthodox Jewish woman recognizes that she must at all hazards bear children. The Mosaic law has practically marked the Jewish woman as unwomanly if she persists in remaining unfructified. One distinct provision of the Mosaic law allows the husband (with the sanction of the wife) the privilege of divorcing her and taking unto himself another wife, if after a lapse of ten years she has borne him no progeny. Strange as it may seem in this land of advanced

civilization, we have thousands and tens of thousands of these classes of women in our very midst today, so that in large cities like New York it is not an unusual occurrence for a woman to consult a physician in regard to her sterility, and acknowledge that her only reason therefor is based on a threat of the husband to take advantage of this ancient provision of Jewish law, and so deeply fixed is the religious belief of most of these women that they are ready to disregard the protection of the laws of the land in which they live and submit to the law laid down many thousands of years ago.

Nor is this true alone regarding the Jewish race. We find that in ancient Rome similar laws prevailed, so that in the time of the Roman emperor, Justinian, we find divorce allowed because of childless marriage. In this case, however, divorce is allowed the woman because of impotency on the part of the male.

3. The greatest portion of our imported population comes from the absolutely illiterate and ignorant classes, hence the artificial methods of preventing conception which have been so thoroughly mastered by the native daughters of our American soil, remains a closed book to them. Such methods as include a diaphragm in one form or another cheat Nature of her original intentions. The use of chemicals to destroy or neutralize the natural secretions so carefully and wonderfully prepared for male and female, the use of metal stems introduced within the womb itself by obliging members of the medical profession, are things absolutely unknown and not within convenient reach of the large mass of immigrant women who swarm to our shores. These poor, ignorant and illiterate women are ready to follow in the same grooves laid down by their mothers for centuries. As a result of this ignorance they give birth to their children in regular cycles, covering eighteen months to two years, until ten, fifteen or sometimes twenty children have been born, and frequently they are not embarrassed when their next accouchement happens to coincide with that of one of their daughters.

The American woman has a horror of large families. She has, however, not yet reached the stage attributed to French

women by Emile Zola, of being ready to sacrifice her reproductive organs in the desire to avoid conception at any cost. But she does, alas, make use too often for her own welfare of every method of prevention of conception and interruption of pregnancy.

In spite of the disastrous results which follow this mode of procedure, it is only fair to state that very few of our women have any serious intention of remaining absolutely sterile. In their efforts, however, to curtail the number of their offspring, they only too frequently do so at the risk of becoming invalids themselves and of inducing absolute sterility.

In seeking to establish the cause of childless marriages, I find that the male is responsible once out of every four or five times. In some races, particularly among the highly civilized, cultured and wealthy, we find that venereal disease is strictly accountable for this. Among the poor, however, particularly of the Jewish faith, evil personal habits are frequently responsible.

In general dispensary practice, where all nationalities are represented, Engleman, of Boston, found the percentage of sterile women to range between eight and eleven per cent. My experience is that in private practice a much larger proportion of women apply for the relief of sterility, and three times as many Jewish women who wish to overcome this condition than women of other religious faiths. In sterility in all classes of women following an effort to interrupt Nature's course during the first period of pregnancy, I have found that thirty-eight per cent of child-bearing women, who subsequently became sterile, could be directly traced to miscarriage occurring early in married life. Abortions occurring before the end of three months accounted for a large number of these cases. One-third of such relatively sterile women unfortunately had suffered from a difficult childbirth, which had left lesions in the organs of reproductioh. One-fourth of such women had suffered from various kinds of pelvic inflammation after childbirth.

The modern woman presents one cause for sterility which her more ignorant sisters from foreign lands seldom show. It is infection with venereal disease of

the genital tract acquired from husbands of a higher civilization and intelligence, but of a lower grade of morals. In a small series of several hundred women applying for relief of sterility, not less than twenty-one innocent wives suffered from the results of gonococcus infection. Allowing that there is no error in the male, and that the woman has no congenital condition to be a bar to fecundity, my experience has been that after a period of from two to five years such women have one chance in ten to become pregnant. After five to ten years the chances are reduced to one in fifty; after ten years the chances are still further reduced to one in one hundred.

These figures are slightly better than for women who have never conceived at all. Still, even in cases of primary sterility there is one chance in ten in overcoming the sterility, and the more seriously the woman looks at the matter from the earliest period after marriage, the better the chances for overcoming the condition. The advice given by some authors to wait until three or four years after marriage until Nature has been given a fair trial is wrong. I should advise no woman to wait longer than one or two years before placing herself under proper medical supervision, and better to place herself in the hands of a thorough student of gynecology, for in no class of cases are greater care and better judg ment required.

112 East Sixty-First Street.

[Written for the MEDICAL BRIEF.] Some of the Difficulties in the Diagnosis of Recurrent Attacks of Appendicitis, with Case Report.

BY RUFUS B. HALL, A. M., M. D., Professor of Gynecology and Clinical Gynecology Miami Medical College; Former President of the American Association of Obstetricians and Gynecologists and the Ohio State Medical Society; Member of the British Gynecological Association; Gynecologist to the Presbyterian Hospital; Member of the American Medical Association; Member of the Academy of Medicine. Cincinnati, Ohio.

The question of diagnosis in an obscure intra-abdominal disease is a very important matter, both to the patient and the physician. Ordinarily it is not difficult

to make a correct diagnosis in recurrent appendicitis. But, occasionally, one sees a case in which the diagnosis of appendicitis is suspected, but very difficult to prove. There are two conditions which may be confounded with and mistaken for recurrent appendicitis. These are a stone in the right kidney, and gall stones. On the first impulse one would say that it did not make very much difference whether a positive diagnosis of appendicitis was made until after the operation was undertaken. But after due deliberation, it must be granted that it would be very much better for all concerned if it were possible to make a positive diagnosis before the operation is begun.

When we duly appreciate these complications we see how necessary it is to be certain of the diagnosis before proceeding with the operation, because if it is a urinary calculi it would be much better for the patient to make the incision in the loin and extirpate the stone in that man

ner.

In a given case where a positive diagnosis can not be made before the operation is commenced, one could make a three-inch incision at the outer edge of the right rectus muscle, the lower end of the incision just over McBurney's point. This would permit exploration of the appendix, the gall bladder and the kidney. If the condition proved to be chronic appendicitis, the incision could be extended, if necessary, an inch lower down, giving ample room for all necessary manipulation. If the condition calling for the operation was found to be a diseased gall-bladder, the incision could be extended upwards. This necessitates a very long incision, however, and is far from an ideal operation for gall stones, and unnecessarily weakens the abdominal wall. For this reason I prefer to make a second short incision just over the gall-bladder for removal of gall stones or for drainage of the gall-bladder. If our exploration demonstrates the presence of a urinary calculi, the stone could be removed by the combined operation of Thornton.

It is most desirable if one can always make a positive and correct diagnosis, and say that this is appendicitis, that is gall-stones, the other one a urinary calculi; and I will grant that in a large

majority of cases, this can readily be accomplished by the careful physician, yet this does not always hold true, as the following case very forcibly illustrates.

Mr. J. L., farmer, aged forty-nine, residence, Camargo, Ill. The case was referred to me on February 13, 1905, by his physician, with an uncertain diagnosis of appendicitis, gall stones, or urinary calculi. The case gave such a varied and complicated clinical history that one could well call it either one of the three, and have a good clinical history, to substantiate the diagnosis. The man was of spare build, always temperate and correct in his habits, a hard worker, and enjoyed most excellent health until early in June, 1904, at which time he was taken suddenly ill with an obscure pain in his abdomen, which continued for about one week. The man was compelled to keep his bed for three or four days, and at this attack he had a slight rise of temperature the first day. The second day his temperature was about 101° F., and the pain was localized in the region of the head of the colon. On the third day after his attack, his doctor was uncertain whether or not there was a slight enlargement in the region of the appendix.

The abdominal muscles over the whole abdomen were rigid. On the fourth day he was better, and on the fifth day he left his bed. He was much needed on the farm and from this on he superintended the labor, but made no attempt to do any manual work for more than a week later. The doctor at that time made a diagnosis of appendicitis, and so stated to his patient and his family. From this until the time he came under my observation the patient said that he was never perfectly well. He was always conscious of something wrong in the right half of his abdomen. The location of the pain varied from the kidney down the course of the ureter, with an irritable bladder, with frequent desire to urinate. The pain also shifted to the region of the gall-bladder, and he was always tender over the gallbladder upon palpation. The skin became slightly colored, like jaundice, but the conjunctivæ were not discolored. He was able to superintend his work until about the first of October, at which time he had a second attack. The pain was

very acute for the first few hours, requiring a hypodermic injection of morphine for relief. The following day his temperature was 101°. All the pain was referred to the region of the kidney, radiating down the ureter, with frequent desire to urinate, with occasional vomiting. The acute symptoms passed off in thirty hours, but he remained in bed, upon the advice of his physician, for five days.

The entire abdominal muscles became rigid and tender upon palpation, and the abdomen became distended with gas. There was no pus or blood in the urine, but with the pain located in the kidney, and the pain paroxysmal in character, the uncertainty of any enlargement of the appendix, the diagnosis was changed to urinary calculi. After a week or ten days he resumed his occupation as before, but always as that of a semi-invalid. His family physician urged him to consult a surgeon, telling him he would have to be operated on before he recovered. The doctor wrote to me in reference to the case at that time. But the patient concluded he would defer the operation with the hope that Nature would cure him, and I heard nothing more from him or his doctor until December, 1904. The doctor wrote me about the 20th that the patient had been ill since the 15th of December with a very sharp attack of pain, and he was inclined to believe now that the patient was suffering from gall-stones. He said the attacks of pain were intermittent, just as gall-stone colic is, that he had extreme tenderness in the region of the gall bladder, that he required morphine in large doses to relieve him; that he was more discolored than heretofore, and there was a slight jaundice of the conjunctiva, and he vomited frequently. He had a temperature for several days during this attack, ranging from 100° to 101° F., and one day the temperature was 102° F. The entire abdomen became rigid, with marked tenderness in the region of the gall bladder and over the kidney, extending along the course of the ureter and especially over the head of the colon. There was never at any time a distinct lump which could be localized in the region of the appendix, and over that region there was always an area of resonance