upon to reduce diphtheria mortality from forty per cent to fifteen per cent. An infected body gets its first aid by disinfection of the blood stream. Purified blood is like godliness; it is a great gain which spreads its beneficent influence into the lymphatics; and gradually the new regime expands into the more inaccessible interstitial tissues, bone substances, etc. In a few individuals, joint pains still follows the administration of the improved antitoxin.

Enthusiastic advocates of serum therapy declare from the housetop that enormous doses, even if they do no good, do no harm. Medicine resembles law so far as it is founded upon the

solid rock of common sense, and a better rule to adopt is this: Just enough is plenty.

Several years ago, diphtheria persistently recurred in the writer's community. The Christian Science Culters were treated by this dangerous contagious disease as impartially as the rain treats the just and the unjust. The loss of a child's life on an occasion or two did not have any more effect on the fools who have said in their hearts: "There is no such thing as disease," than water on a goose's brain. But sometimes when it rains, it pours. Diphtheria turned itself loose in the family of a Christian Science healer. And like Enoch of old, she was not, because diphtheria took her.

S

URGEONS and pathologists long have been familiar with "appendicitis obliterans"-total obliteration of the lumen of the appendix through inflammatory influences. That a similar state of affairs may result in the cystic duct from like cause is not, I believe, a fact well established; certainly it is not generally known. The following case-history demonstrates it beyond question:

Mrs. Ellen W., of Cuba, Mo., patient of Dr. J. H. Martyn, was admitted to the American Polyclinic Hospital November 24, 1913. She is 53 years of age, always of perfect health until about one year ago when she had some pain in region of gall-bladder accompanied by slight fever. Early in September of present year she had a rather severe attack of gall-stone colic ("pain under the liver", as she described it) with vomiting and fever, though temperature never ran above 102. For the past four weeks there has been a gradually deepening jaundice, accompanied by nausea and occasional vomiting together with constant distress in the region of the gall-tract.

Operation on November 25, revealed a small, contracted gall-bladder, with walls enormously thickened (as much as one-half inch in places) attached to every neighboring structure. After the bladder was liberated, with great difficulty, search was made for stones in the ducts; none

could be found, although the ducts were easily traceable from liver and from gall-bladder to the duodenum. Dr. Sam W. Kelley, of Cleveland, who kindly assisted me in the case, agreed with me that the jaundice originated from inflammatory obstruction instead of from obstruction by a stone, as supposed prior to operation. When the gallbladder was opened there was found to be no bile; the stones were in a kind of mush consisting of the remains of bile, mucus and shreds of mucosa.

Search for more than half an hour showed con

clusively that there was no communication between the gall-bladder and the common duct-the cystic duct was entirely obliterated, the remains being nothing but a cord-like structure. Therefore the gall-bladder was removed.

Some of the enlarged lymphatics contiguous to and pressing upon the common duct were removed and found to be purely inflammatory in character. The wound was closed with gauze drainage.

Bile came through the drainage tract on third day, and appeared in the stools on the fourth. The jaundice promptly disappeared, with speedy convalescence.

Later an operation for formation of a new duct from a piece of intestine will be performed if it is found that the common duct has also been destroyed or injured to such degree that restoration of function is impossible.

I

IT is essential in order to appreciate the true standing of medicine, that we know something of its history. Natural man inherited certain instincts that he lost after the advent of civilization. Organizations, creeds and isms in medicine have obscured a certain amount of truth. Medicine has developed by a process of evolution and we find, in studying its history, that its development has been just about as rapid as has been the intelligence of the existing state of society of the particular period we study.

One investigator truthfully says: "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. 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."

The science of medicine is no exception to the rule. If we know the condition, habits, mode of government, etc., of society, of any particular period, we can determine the standard of medicine at any period in history. When the free lands were suppressed and private property was inaugurated the first movement was to develop master and slave. The natural result of such a system was a destruction of natural instincts. The chief of the tribe, the general of the army, and, in time, the priest of the flock, became the medicine man.

The priest-doctors, who claimed the honor of having a special dispensation from God, formed a medical monopoly, and by imposing upon the credulity of the masses formed the basic principles, planted the seed of that giant monster that we have to contend with today-medical commercialism. There never was a reformer from the dawn of civilization who escaped the insults, falsehoods and brutal attacks of the crowd that followed this false system of medicine.

Only a few years ago one of the greatest medical men that has ever lived, one whom you would suppose from his pure life and honesty of purpose

would have been received with open arms, made the following statement:

"When a boy I determined to treat all men with politeness and to endeavor to devote all my powers of mind and body to the promotion of the welfare of mankind-of the greatest good to the greatest number; and I thought, in the simplicity of my heart, all men would love me for it. Though I am not conscious of ever having deliberately deviated in a single instance from my purpose, yet, perhaps, no man of my age has been more violently assailed by the tongue of slander. Though I have endeavored to learn all I could, been strictly honest, and devoted all my life to deeds of benevolence and the relief of a suffering humanity, I have been called an ignoramus, a knave, and a murderer (an anonymous letter from one of the most benevolent in the profession said that I deserved and might expect hereafter to roast on the burning coals of hell!). Still, in the language of One whose spirit I would endeavor to imitate, I can say that none of these things move me, so that I finish my course, relieve human woe, and leave the world better for having lived in it. What care I, what need I care for the envious and malicious whinings and calumnies of a few obscure dabblers in physic whose only title to a parchment has been gold, or favoritism, or perhaps the approbation of a county society as stupid as themselves or, what is more common, a sort of right of possession, gained by a long course of practice in the use of those deadly drugs, of which the law is a safeguard, so long as I am countenanced and supported, aided and encouraged, by a host of learned and benevolent professors."

Let a man tell the truth, offer the least protest against this system of falsehood, and at once the cry goes up, "crucify him"; but in the course of evolution things change and today men are searching for the truth and accepting it no matter where it is found. The priest-doctors of the olden times placed a burden on medicine, originated a false belief, and made the road clear for a system of nosology that caused many to look upon disease as an entity-a monster devil. Only by the greatest endeavor was the art taken from these breeders of false doctrines, and then after this being accomplished we have been all these years trying to restore the science to natural methods.

With the coming of the rulers and the titled,

society took on such laws as were required to enforce the mandates of those in power. Clubs, guns, bayonets and brutal force in general were first used, then, as time went on, a more refined system was introduced. The courts of modern civilization take the place of the old battle fields. During all these centuries, while these changes are in progress, medicine also makes her changes. The masses in the profession following the customs of the times, giving little if any thought to the true principles of medicine. This art has had her generals, judges and rulers. The priest-doctors had their ethics and when the new rules were made by the successors of the God-appointed (?) priestdoctors some of the customs were still retained and he who would not comply must perish.

One

The priest-doctors were a wise class. They learned the medical art from the religious corporation that existed and each one of them took a vow never to reveal a secret to the masses. of their ancient laws said that "it is not permitted to reveal sacred things except to the elect and strangers must be admitted to this knowledge only after having submitted to the tests of initiation."

Temples of the god of medicine were erected on a hill or in the mountains. Healthy and beautiful locations were selected. The people would come from far and near to be cured of their maladies. All kinds of trickery and deception was practiced. Renaud says. "there existed in the country about Epidaurus and in various other localities serpents of a yellowish brown color whose bite was not venomous and which were easily tamed. The priests employed them in those supernatural performances which filled the people with astonishment and superstition."

When Rome was ravaged by a terrible pestilence in 350 B. C., the Senate sent six deputies to consult the oracle of Epidaurus. As soon as they arrived at the temple and while they were admiring the statue of the god, an enormous serpent issued from beneath the pedestal and moved through the crowd, entered the vase of the Romans in the chamber of Ogubinus, the chief of the ambassadors. Aurelius Victor says that the sacred reptile was piously borne away and when the vessel of the ambassadors was approaching the city of Romulus, he sprang into the waves and swam to an island in the Tiber. A temple was immediately erected to Esculapius on that spot and the pestilence ceased.

In every age we always have a certain class of individuals who can love above the influences of false doctrines and superstitions and although the great majority did then, as they do now, accept all the fraud and deception that is practiced, a few

will without fear or favor tell the truth. The truth shall live.

Aristophanes investigated these prodigies of the priest-doctors and witnessed the fraud. He says: "the priests of the temple of Esculapius, after having extinguished all the lights, told us to go to sleep, adding that if any one should hear a hissing, which indicated the arrival of the god, he should not move in the slightest manner. So we all laid down without making any noise, but I could not sleep, because of the odor of an excellent broth that an old woman held near me, agreeably exciting my olfactories. Desiring most ardently to slide along to it, I raised my head quietly and saw a sacristan who took away the cakes and figs from the sacred tables, going the round of the altars, putting into his sack everything he could find. I believed that I had a right to follow his example so I raised to go to the old woman's pot." And thus was the god of medicine and food disposed of by the hand of one of the priestdoctors' confederates.

art.

This gives us a glimpse of part of the deception practiced by some of the early organizers of our After the natural man lost his natural instincts, he became helpless and the prey of the ruling classes. Natural medicine was used only as preserved by the priest-doctors, and in order to mislead, all kinds of fraud and trickery were practiced.

The degeneration of science was injected into art at this time. Only by a great effort was medicine taken from these pseudo-scientists, and when it was, many of the forms, customs and habits were retained. All these years have been spent and many a true reformer has been sacrificed in the attempt to purge the art of its false doctrines and practices. We dare challenge Galen, we shall dispute Hippocrates in order to save the

art.

[EDITOR'S NOTE.-We hope that Dr. Horne will continue the discussion of this topic so promisingly discussed in this issue. We are all anxious to study the development of "authority" in medicine.]

A little town in south Texas does its lazy best to support three hotels. Each sends a negro porter to meet the diurnal train, where they vie with one another, as only darkies can, in their attempts to get the few traveling men who stop. At the present time, one of the big, good natured negroes, who seems to know human nature. is calling out, "Right dis way fo' de State House, de bes' secon' class hotel in town." Then, with a broad grin, he adds, "Dey ain't no fust class.''

T

HE "knock-out" blow is a very curious phenomenon, which always surprises those who may be witnesses of it during a prize fight. In the course of a fight, when both adversaries appear to be in perfect condition, and animated by an equal degree of energy, one of the boxers suddenly stops; his arms drop, he looks fixedly in front of him, his features are immobilized, his limbs relax, his body inclines forward, to one side, or backward, and then he falls "all in a heap." This scene is enacted with stupefying rapidity.

The unhappy victim of the knock-out blow remains quiet for a variable degree of time. Sometimes the attendants are obliged to carry him out before bringing him to his senses; but more frequently he comes to himself at the end of a few seconds. Then he seems to be coming out of a dream and appears to have no consciousness of what is passing about him. Often he is restored rapidly to his senses, gets up and may return to the fight, which sometimes turns out to his advantage.

We have questioned a large number of fighters regarding the subjective sensations of the knock-out blow, and here is the information which we have obtained from them. In some cases the loss of consciousness is instantaneous and the boxer can recall nothing of the circumstances which preceded it. Occasionally he asks if it is time to go on with the fight on coming to his senses.

Frantz Reichel has seen some of these men protest with energy when told that they have been beaten by a knock-out blow, but in general such a complete loss of consciousness is quite rare and entails peculiar sensitiveness on the part of the subject, or at least a very violent traumatism.

More often all that is experienced is a giddiness and a semi-conscious state, which does not prevent the victim from remembering his sensations. The latter vary in different subjects, There may be a dazed sensation, or a sensation of cerebral concussion, or one of nausea. A few boxers assert that they have experienced a sense of well-being, but the most frequent and most

Translated from Paris Medical, Dec. 13, 1913.

constant phenomena are those of vertigo and auditory perception, ringing in the ears, etc.

Traumatism on any part of the body may cause the knock-out but the form of most interest to us is the knockout produced by a blow on the lower jaw. In reality, while it is necessary to have an extremely violent shock in the carotid region, or in the epigastric region to knock down a boxer, a blow relatively light on the jaw suffices sometimes to produce the knockout. A direct blow, but more often a "hook" on the chin, provokes almost always a momentary loss of consciousness, and frequently a fall without loss of consciousness. The classical blow is a "dry hook," often hardly perceptible, but applied in a definite and well determined direction.

Explanation Of the Knock-Out.

To what is due this terrific effect, which appears to be out of all proportion to the intensity of the blow on the jaw? According to Sebileau, the knock-out is caused by a sudden and violent displacement of the cephalo-rachidian liquid. Pagès writes on this subject: "The true knockout seems to be an interruption of the nerve current as a result of the intense vibration of the inferior maxillary nerve. The boxer declares the knock-out to be like a current which has been suddenly interrupted, and that he comes to life when the 'contact' had been re-established. It is probable that there is at the same time an intense vasomotor action on the nervous centers. Severe pain seems to prevent this reaction. In fights with the naked fist, or when the face is severely bruised, the knock-out is very rare."

Léon Sée explains that a sharp blow on the chin, forming a lever, produces a sudden displacement of the head, which by a counter blow (contre coup) is thrown back on itself. The result is a vibration of the cerebral mass and as a result of this action an interruption of the nerve communication, followed by loss of consciousness.

This last explanation is generally admitted in the boxing world.

My personal opinion is that this explanation is irrational, since a blow directly on the regions in immediate contact with the brain, as on the forehead or temple, is more likely to produce the phenomenon described to explain the knock-out

than a blow on the lower jaw; and furthermore, it is observed in practice that violent blows on the cranium are often without effect, while the least blow on the chin nearly always stuns the adversary.

It is true that a severe blow on the head may produce loss of consciousness, but such a loss of consciousness presents grave and lasting symptoms, which have no analogy to the benign and fugitive character of the ordinary knock-out. It is for this reason, moreover, that boxers constantly seek the lower jaw, which is recognized as the weak point or place of election for putting an adversary to sleep without great danger.

It will therefore be seen that blows on the lower jaw possess a peculiar character, which leads us to believe that the knock-out is produced by a special kind of mechanism of which we shall now attempt to give an explanation.

We have already seen that the knock-out is nearly always preceded by auditive sensations, such as ringing in the ears, the sound of a clock, whistling, etc. We may then ask ourselves if the knock-out does not have for its essential cause an auricular irritation, possibly analogous to Ménière's vertigo. We know that Ménière's vertigo is characterized by: (1) auditive sensations-buzzing, whistling; (2) nausea and vomiting; (3) vertigo, accompanied by clouding of the intelligence and by a fall forward or on the side. The paroxysm lasts from a few minutes to a quarter of an hour.

These are virtually the symptoms observed in the knock-out. Ménière's disease is due, perhaps, to hypertension of the labyrinthine liquid, perhaps to a lesion of the internal ear in which the semicircular canals are placed, organs which certainly play an important role in equilibrium. The semicircular canals receive the vestibular nerve, which takes its origin in the medulla in three nodes: first, the node of Deiters; second, the dorso-internal node; and, third, the node of Bechterew. From these three nodes fibers emanate, part of which are directed toward the cerebellum and the others toward the cerebral cortex. In this way every irritation of the semi-circular canals promotes a bulbar, cerebellar and cerebral reflex. The cerebellum being the organ of equilibrium, a concussion of the semicircular canals produces vertigo and disturbances of equilibrium.

These facts being understood, we can understand the mechanism of the knock-out. The temporo-maxillary articulation is contiguous to the auditive apparatus. The glenoid cavities, in which the condyles of the inferior maxillary are

placed, are hollowed out in the temporal bone, and in this way are intimately related to the internal ear. A shock on the chin is transmitted to the glenoid cavity by means of the condyle of the maxillary, as internal concussion produced on the ear and the semicircular canals, and a bulbar, cerebellar and cerebral reflex results, which engenders all the characteristic phenomena of the knock-out.

This interpretation of its mechanism also ex- plains the fact that a lateral blow on the chin (a hook) is more effective in producing a knockout than a direct one from the front' in the middle of the maxillary. In reality, a lateral blow on the chin produces a shock in the glenoid cavity of the opposite side only, while a median traumatism, applied in the middle of the chin, transmits the blow to both glenoid cavities and thus the force is distributed over two points instead of being exerted at one only as in the. first instance. We can understand, therefore, that the violence of the shock would be considerably greater in lateral traumatisms than in the direct ones. Furthermore, the disturbance of equilibrium is more accentuated when the irritation is felt in the semicircular canals of one side only than when it is bilateral.

The objection that can be raised to this analogy between the knock-out and Ménière's vertigo, is that in the latter disease there is rarely loss of consciousness, while it is frequent in the knock-out. However, we may reply that the irritation caused by Ménière's disease is without doubt less brutal and particularly less sudden than that provoked by the traumatism producing the knock-out; and, furthermore, loss of consciousness is sometimes observed in Ménière's disease, and it is not an absolute rule in traumatism of the lower jaw. If the blow does not reach a certain intensity, there is usually only ringing in the ears, vertigo and loss of equilibrium, sometimes accompanied by a fall, and without loss of consciousness. Very frequently the patient does not even go to the ground. He is, as they say, "knocked out standing".

Dr. Babinski, to whom we have submitted the preceding, has approved this explanation of the mechanism of the knock-out blow. He thinks that if in the knock-out there is loss of consciousness, the irritation of the semicircular canal is associated with cerebral concussion. Drs. Heckel, de Martel and Vincent, who practice boxing, and some of whom have known the sensation of being knocked out, also accept this interpretation of the mechanism of this phe

nomenon.

"