gummatous ulcer, usually multiple, and a diffuse syphilitic infiltration with variable degrees of contracture, thickening, deformity, and perigastric adhesions, chiefly involving the pyloric segment, is the usual pathological condition. Demonstration of the Spirochaeta pallida in resected tissue would be final proof. Results from antisyphilitic treatment are encouraging in all but very advanced cases. Sometimes surgical intervention is indicated. Early diagnosis and intensive treatment invariably result in symptomatic cure and structural improvement.

Bacterial Etiology of Rhus Poisoning-Lowell C. Frost (Medical Record, December 23, 1916) presents the following points in favor of the bacterial origin of ivy poisoning: the incubation period averaging four and a half days, complete natural immunity in certain individuals which may be lost through lowering of the physical resistance, and the appearance of the exanthema in an area untouched by the plant directly. Cultures made by Frost from the leaves of the plant showed only one constant type of bacteria and this was a short, thick bacillus, aerobic, spore producing, giving an abundant growth on potato at room temperature. Inoculation by inunction of pure culture, after forty-eight hours produced only a slight redness of the skin without itching or burning.

Fulminant Cerebrospinal Fever-P. W. Maclagan and W. E. Cooke (British Medical Journal, December 23, 1916) states that they have seen over a dozen cases of this form of the disease, all ending fatally. There are two types of this form of cerebrospinal fever. In the one there may be an intense meningococcal bacteriemia without any meningeal involvement, or with very slight involvement. In the other there is also an abrupt onset with almost immediate unconsciousness and beginning signs of meningeal involvement, giving place to complete muscular flaccidity. In both types the fatal progress is very rapid, with signs of total failure of the blood pressure and the heart. The two chief characteristics of this form of cerebrospinal fever are the occurrence of a hemorrhagic rash varying from petechial spots to hemorrhages of several square inches, and the presence post mortem of hemorrhagic destruction of the suprarenal glands. The latter probably accounts for the rapid fall of blood pressure and cardiac failure as well as for the muscular flaccidity. It is suggested that the organism may possess an affinity for the chromaffin structures of the adrenal glands and probably also for the cortical layer which is similar to the myelin of the central nervous system.

Clinical Studies of Acidosis-J. H. Austin and Leon Jonas (American Journal of Medical Sciences, January, 1917) tell us that in the new methods for studying acidosis directly from the blood we have a means of investigation which is a distinct advance upon our previous methods. As criteria of the supply of "buffer substance" in the blood, the carbon dioxide capacity of the plasma, the hydrogen ion concentration of the serum, and the alveolar air give results that are in general parallel, but the first is the most sensitive and gives much more satisfactory duplicates than does the alveolar air determination. It affords a simple and quick method of determining the presence and degree of acidosis. Reference must be made to the original for a full description of the method.

The Etiology of Acute Articular Rheumatism-Fr. Rolly (Mediziniche Klinik, November 5, 1916) points out that the similarity between certain of the more important symptoms of anaphylaxis and of rheumatism has led to the suggestion that the latter disease is merely a manifestation of an anayphlactic condition due to the entrance into the circulation of bacterial protems or protein products from focal bacterial lesions. Such a view cannot be accepted as offering a complete explanation of the rheumatic symptoms, since certain of the most characteristic of these symptoms are almost never encountered in cases of known anaphylaxis. Among these the most important is the occurrence of the local phenomena of joint swelling, redness, and pain. The suggestion of the anaphylactic mechanism of rheumatism is based upon isolated resemblances in symptoms rather than upon a true close similarity of the manifestations of the two conditions. On the other hand, the theory that rhematism is a bacterial entity entails many factors of doubt which can be brought up against its acception. Thus, there is no evidence that the organisms which have been isolated from the surfaces of the inflamed tonsils in acute rheumatism are the true pathogenic organisms, for the same organisms can be isolated from tonsils of normal persons and have similar degrees of virulence for the lower animals. Further, there is no uniformity among different workers as to specific characters of the organisms isolated. Finally, it may be pointed out that positive cultures from the blood, the affected joints, and other body fluids in cases of acute rheumatism are quite uncommon, and that a very large proportion of cases of acute rheumatism develop in the absence of any demonstrable inflammation of the tonsils, or other pharyngeal structures. In the state of our present knowledge it is impossible to say that we yet know the true etiology of the clinical disease which we call acute rheumatic fever.

Aural Typhoid Carriers-A. B. Bennett (Journal A. M. A., January 6, 1917) reports two cases of this rare condition. In one there was a chronic suppuration of the middle ear with purulent discharge dating from a severe attack of typhoid fever eighteen years before. From the pus, living typhoid organisms were cultivated on two occasions. The other case occurred in a child, fifteen years old, who had never had an attack of typhoid fever. The ear trouble began with a frank attack of purulent otitis media, which left a chronic discharging ear, from the discharge of which typhoid organisms were isolated. Local treatment combined with the administration of typhoid vaccine materially benefited the first case, which was lost sight of before cured; and cured the second. In neither case was there evidence that any other person had been infected as a result of contact, but the possibilites of such an occurrence should be borne in mind in such cases.

Burns from Missles-George Magnus (Medizinische Klinik, November 5, 1916) says that much of the tissue destruction caused by certain forms of missles is not to be explained on the basis of mechanical traumatism, but is demonstrably due to the effects of burning produced by the great heat of the missles. The lesions, if carefully studied in all their forms and grades of severity, show evidences of actual burns of all degrees of intensity, and the tissue destruction caused is both too extensive and too prompt, in the appearance of its manifestations to be accounted for on the basis of contusion. The missles which are most likely to retain sufficient heat to cause burns are fragments of grenades and high explosive shells, bombs, and shrapnel. It is in the cases of injury from just these missles that the instances of extensive tissue destruction is encountered. Occasionally, also, actual burning of the clothing overlying the areas of such wounds, or where fragments of such missles have struck glancing blows, is encountered.

Vesical Calculi Following Wounds of the Bladder.-F. Leguen (Bulletin de l'Academie de medecine, December 5, 1916) states that he observed calculus formation after a long or short interval in ten out of thirty-two cases of bladder wound. In a few of these, in fact, recurrent calculus formation occurred. Infection has been held to account for this complication of bladder injury, but he found that the duration and virulence of the infection was no greater in the cases that manifested calculi than in the remainder. A striking coincidence of calculus formation with fracture of the pelvis was, however, noticed. All the cases with calculi had a pelvic fracture, and no calculus developed in any of the twenty-two cases without

fracture. This relationship is ascribed by Legueu to the doubly compound fracture produced in military bladder wounds. The fracture communicates both with the exterior and the bladder. Urine passes out to the fracture site, while pieces of bone pass into the bladder, where he sometimes found them firmly embedded in the bladder wall or included in the center of a calculus. Even when there are no more bone splinters, simple osseous particles continue to pass through the sinuses, and to these are ascribed the frequent secondary stones. Long after healing of the external wound, a deep lesion of the bladder was noted by cystoscopy or at operation, the attenuated bladder mucosa pouching out widely to line the depression in the bone. resulting from the fracture, with a minute sinus at its base connecting the focus of osteomyelitis with the bladder. Through this channel bone dust falls to the fundus of the bladder, remains there while the patient is abed in dorsal decubitus and constitutes a nucleus for stone formation. These stones are soft, friable, white, and may contain a small sequestrum. Operation to separate and close off the bladder from the bone, failed, the wound in the repaired bladder being reopened. Lithotrity was then adopted as the proper procedure. Bone splinters in the calculi were withdrawn instrumentally through the urethra after crushing of the stones. For recurrent stones repeated lithotrity is indicated.

PYLORIC STENOSIS.

Leon T. LeWald, before the New York Academy of Medicine, in speaking of the various degrees of pyloric obstruction and the ingenious theories which have been advanced to account for its origin, said one was forced to the conclusion that, after all, little had been gained by these controversial theories and that they did not tend to assist very materially in an elaboration of the diagnosis, nor to establish a definite form of treatment, which was, after all, the important and practical end which was sought. Certain cases which exhibit the classical symptoms, namely, projectile vomiting, steady wasting, constipation, excessive stomach peristalsis, in addition to a palpable nodular tumor in the pyloric region, we must regard as cases of true pyloric stenosis. Enough cases have been reported with marked hypertrophy of the circular fibers of the pylorus, and a corresponding diminution in the lumen of the viscus at this point, as is shown in the illustration on the screen, that it would seem irrational to deny the existence of this type, which may be termed surgical. On the other hand, cases are reported without any palpable tumor, but otherwise having all the usual sypmtoms in varying degrees of severity. It is perhaps in these that the greatest difficulty arises in determining the

best method of procedure and in how far they may be surgical. The suggestion is given by the majority of writers that this group should be treated medically until the time when they resist medical management, as evidenced by stationary or falling weight. They may then be subjected to laparotomy, with its high degree of hazard, the operator being necessarily uncertain as to his method of procedure until he has satisfactorily explored the stomach. If a hitherto undiscovered tumor is found at the operation, the infant must be able to withstand a considerable degree of shock incident to the performance of a posterior gastrojejuostomy. If no tumor is found little is gained and possibly much lost by subjecting the impoverished infant to a loss of blood and further depletion of its natural existence. If, therefore, by the use of modern methods we can so complete our diagnostic means that we can, with a degree of positiveness, determine whether or not a given case shall be operated upon, we shall be making an advance worth while. Notable achievements have recently been made in Roentgenology, especially in the use of bismuth in the alimentary tract. Modern apparatus, with the intensifying sheets, enables the radiologist to make instantaneous exposures, thus securing with the minimum of effort negatives of value. Whether the stomach in early infancy is simply a dilated pouch intended for the accumulation of a quantity of food, which is quickly acted upon by the gastric juice and immediately allowed to pass out through the pylorus, or whether it performs its share of the preparation of foods for the higher and more complex process of digestion in the duodenum, is a question for future study. The fact that we may observe the exit of food into the duodenum within a minute or two after its intake tends to show that we have been overvaluing this portion of the alimentary tract. That liquid foods begin to be expelled normally in a very short time after they are taken into the stomach is very helpful in our diagnosis of conditions dealing with some forms of pyloric obstruction, for if it can be demonstrated with a degree of exactness, by a series of radiographs, that the milk is retained for a greater length of time than in the normal stomach, as is shown by the bismuth shadows, we can determine with a fair degree of certainty with what type of obstruction we are dealing. Since such striking results can be obtained by this means, it seems manifestly unfair not to early obtain a series of radiographic pictures in every suspected case, so that an infant suffering from a true tumor and with a lumen so small as to practically occlude the passage of food into the duodenum may early be given over to the surgeon while its physical condition is still good. On the other hand, cases of pyloric spasm, even of marked degree, but without tumor formation, can be differentiated, since the time and the amount of the