any other conditions we have studied, hence would seem to have some diagnostic importance.

DOCTOR KLINGMANN (closing the discussion): The patients who go. without sleep for long periods, as Doctor Barrett has just mentioned, show very clearly that the toxic theory of physiologic sleep is not well founded. It would be interesting, however, to inject blood serum from such patients into animals to determine if it would produce sleep in the latter.

A CONSIDERATION OF SOME OF THE DANGERS OF OVERINFUSION WITH SALINE SOLUTION.

DOCTOR CONRAD GEORG, JR., contributed a paper bearing this title. (See page 10.)

DISCUSSION.

DOCTOR REUBEN PETERSON: Doctor Georg has brought up for discussion a very important subject and it is a pity that the hour is so late. Practically I find that it is very difficult to determine at a given operation just how much blood has been lost. Pallor and increased pulse rate, while aids, are apt to be brought about by other operative causes. There is no question but what the intravenous injection of salt solution acts more quickly, yet it must not be lost sight of that it is not devoid of danger. One may inject too much and there is always the danger of the introduction of air. Clinically, if the patient is so far reduced from loss of blood or shock or both that the saline cannot be absorbed subcutaneously, I have found that matters are not helped much by the substitution of the intravenous method. In other words, when this point has been reached, the effect of the loss of blood and the shock of the operation upon the heart and the great nerve centers has been so severe that saline no matter how introduced has very little effect.

We must not lose sight of the fact that one great error in technic of giving salt solution is that it is not given hot enough. Through a faulty apparatus it is far below 110° when it enters the circulation and may even add to rather than diminish shock.

I have no doubt in many instances, results such as Doctor Georg reports from his experiments occur in the human from giving too much. salt solution.

REPORTS OF CASES.

HOOK-WORM DISEASE AND MULTIPLE LIPOMATA.

HARRY B. SCHMIDT, M. D.

Department of Medicine.

R. B., male, aged fifty, a South American planter, entered the University Hospital November 13, 1911, complaining of multiple swellings beneath the skin which he thought were due to filarial disease. His family history was negative. He had had several attacks of malaria, the last, two years ago. The first subcutaneous tumor appeared six years ago beneath the scapula on the left side. Since then numerous

tumors have appeared on various parts of the body which have varied somewhat in size, apparently becoming larger when he was not feeling well. On examination these tumors, which were numerous, appeared to be situated in the subcutanous tissues, being freely movable in regard to both the skin and the deeper tissues. They were soft, irregular in shape, not tender, and bore no relation to the nerves or lymphatic glands. Pathologic examination of one that was removed showed a lipoma.

The blood was negative for filaria but the differential count of the leukocytes showed thirteen per cent of eosinophiles. A careful examination of the stools showed fairly numerous motile embryos of the uncinaria americana and after centrifugalization a small number of typical eggs. Eggs of tricocephalus dispar were also found. Adult uncinaria were recovered after treatment with thymol.

It is interesting that the motile embryos in the stool were more numerous than the eggs in the first specimen examined although the stool was fresh. The condition apparently produced no symptoms and would not have been suspected except for the residence of the patient and the eosinophilia. DISCUSSION.

DOCTOR MARK MARSHALL: This case is particularly interesting because we see so few of them at this hospital. Of course we will not know whether this patient is cured until we have examined the stools further for the eggs of the hook-worm. The average case requires four or five courses of thymol; in many cases eight or ten treatments are required to bring about a permanent cure. I think the disease is most interesting because of its being so widespread in certain localities and because of its influence upon the mental, physical, sociologic state of the people affected. In Porto Rico there are seven hundred thousand peasants and most of them are infected with hook-worms. The average hemoglobin of these people is only forty per cent. This is shown in the inefficiency of the laborers. The work of treating all of these cases was undertaken by the Medical Department of the United States Army under the leadership of Doctor Ashford who was placed at the head of the first anemia commission of Porto Rico, and when one considers the very small amount of money at their disposal the work accomplished is really remarkable. During the fiscal year of 1907-08 they had at their disposal fifty thousand dollars to be used in the treatment of hockworm disease. They established thirty-five treatment stations throughout the island, some equipped for taking bed patients. Most of them, however, were run simply as dispensaries. The personnel of one of these hospital stations was one physician on a salary of one thousand dollars per year, an assistant and nurse and one servant, the tota! expenditure for salaries for the year being fifteen hundred fifty dollars. The dispensaries had one physician at seven hundred dollars a year, one assistant and one nurse, a total of a little more than one thousand dollars a year.

During the year 1907-08 they treated ninety thousand cases accord

ing to the method outlined in Doctor Schmidt's paper which means that ninety thousand stool examinations had to be made in order to make definite diagnoses. The stools were examined once a week thereafter, which made in all a total of five hundred thousand microscopic examinations carried out at these thirty-five stations. This work was done at a cost of fifty-four cents per case, which is remarkably low and speaks well for the organization engaged in the work.

DOCTOR ALBION WALTER HEWLETT: That these two patients are here is due to the fact that we have attracted students from South America. In regard to the patient with the hook-worm disease, he was very nervous. He had tumors all over the body and was told that they were due to filaria. I brought him into the hospital chiefly in order to remove from his mind the feeling that he had some serious disease standing over him. We were able to get him in a better frame of mind partly by showing him that these tumors were nothing but fat, and that he had some hook-worms which were removed. Possibly the latter were responsible for his general nervous condition, but aside from that they produced no symptoms.

REPORT OF A CASE OF AMEBIC DYSENTERY.

LUTHER F. WARREN, M. D.
Department of Medicine.

The patient entered the University Hospital on Friday, November 17 complaining that he was gradually growing weak and had distress. and uncomfortable feeling in the stomach region, made worse by eating. He had a mild diarrhea, having when he entered five or six movements per day. He was twenty-eight years of age, a merchant, and was from South America. His family history was negative.

He had malaria at nine, and again at nineteen. At the age of sixteen he had gonorrhea. Five years ago he had swollen inguinal glands which suppurated and remained so for five months. He denies specific disease. Further than this his personal history is negative.

His present trouble dates from ten years ago. In the Columbian revolution he was cast on an island and was starved. He remained here for four months and became so hungry that he would eat the palm leaves. These, he said, would irritate the stomach; then he would vomit them, and then eat the vomitus. The patient says he has never been well since, being troubled, as I have said, with these symptoms on the part of the stomach. These have gradually progressed up to three years ago when he had a severe attack of diarrhea and noticed at this time a large amount of mucus in the stools. He did not go to bed, but took ipecac and placed himself on a diet. In a short time he got relief. He remained well for about a year. Then two years ago he had another attack of bowel trouble and noticed blood in addition to the mucus. He again repeated his own remedy and when he came to us he was having a third attack of a similar nature, his treatment not being as satisfactory as previously. He would pass as many as ten

stools per day. They were watery in character. It has been said that in the case of a patient with amebic dysentery one thing is easy and that is getting the stools; whenever we wanted a warm stool for examination and would ask him to save one he would say: "You can have one right now if you want it."

His symptoms fall in very well with those described by those who have seen many of these cases, and particularly by Strong, who places gastrointestinal symptoms first, including nausea and vomiting. During the attacks of diarrhea bloody mucus appears in the stools. Patients do not have very marked pain, particuarly in the form this patient presents. There are severe pains in the acute forms.

The urine was negative. The stomach showed subacidity, on a full meal at four hours, free 8, total 24; on a shredded wheat biscuit at fifty-five. minutes nothing was obtained; on one at forty-five minutes, So cubic centimeters, free 12, total 20. His blood showed evidences of concentration-6,000,000 reds on entering, 18,000 whites and ninetynine per cent hemoglobin. A differential count showed 22 lymphocytes, 2 transitionals and 22 eosinophiles, fifty-four per cent polynuclears. As eosinophilia is not a finding of amebic dysentery, careful microscopic examination showed the presence of eggs of both the uncinariasis and trichocephalus dispar; these were the causes of this finding and in severe infections might cause symptoms of which this patient complained. Examination of the mucus of the stools, however, showed the ameba. On account of the rapid motion and intrusions of red blood cells it belonged to the pathogenic group. Inoculation into the bowels of the dog or cat was not done. This is done to determine the pathogenicity. After thus making the diagnosis the man was placed on treatment. Of the two methods most usually employed, quinine injections and the ipecac treatment, the latter was employed. After cleaning this man out thoroughly with calomel and salts we gave him sixty grains of powdered ipecac coated with salol and gave a liquid diet. This was repeated daily and on the third day he had eight stools, became nauseated, and vomited, for which we gave morphin, and again gave him forty grains of ipecac per day. Two days later he became restless, morphin was given again and the ipecac still continued. This was dropped to ten grains per day durng the past week. For the past week the examination of stools has failed to show any occult blood, although up to that time this was present. Yesterday he had but one stool, and today up to this evening has not had any stool. The stool passed now is free of mucus. Proctoscopic examination shows mucus membrane intact, no ulcers, no bleeding points. Neither eggs nor amebæ can be found. Patient was discharged with advice as to treatment and diet. DISCUSSION.

DOCTOR JAMES G. VAN ZWALUWENBURG: The principal interest in this case is its novelty in this neighborhood. We should not lose sight of the fact that these cases occasionally occur here. About four years ago a person came to the University Hospital from Detroit, the patient never having been outside of Michigan. He complained of considerable

looseness of the bowels and of tenesmus before that. Examination of the stools demonstrated the presence of trichomonas and circomonas and there was constantly blood in the stools. On the basis of this a diagnosis was made of ulcer of the rectum and the case was reported as one in which undoubtedly the trichomonas were the cause of the ulceration. The patient returned two years later with practically the same symptoms in spite of continued thymol treatment and other intestinal antiseptics. He came in during the exacerbation of his trouble. The very first examination showed active amebæ in the stools. He was kept under observation for several days and every stool thereafter showed more or less active amebæ. The man was treated and although he never entirely lost the amebæ, he became very comfortable and since that time has been at work in this town and has had no further trouble. The organisms undoubtedly live in Michigan. The source of infection, as near as we could trace it, was from a contractor's well in the River Rouge district. The man had practically never been outside of Wayne and Washtenaw counties and since the infection is not common in Detroit, we are loathe to lay the blame on the Detroit water supply; also there were one or two other cases in the immediate neighborhood, traceable to the same well. This is very exceptional, and still it shows the possibility of the disease being in Michigan.

In most cases the diagnosis is comparatively easy. It is not a difficult feat to find the amebæ if one properly undertakes it. Probably the best and easiest way is to pass a rectal tube a few inches into the bowel, then withdraw it and examine the mucus that adheres to it; this almost invariably shows ameba if they are present. It is almost impossible to recognize them in a cold stool because of their resemblance to other bodies occurring normally or accidentally in the stool. The diagnosis must rest on the finding of actively motile ameba which is practically impossible in the winter without a warm stage; in the summer time it is comparatively easy. The most striking characteristic of entameba histolytica is its very active movements. Of course it is not the only ameba in the bowel, but it is comparatively easily recognized from the fact that its movements are so brisk and so active.

DOCTOR ALBION WALTER HEWLETT: It is interesting to note that in the Canal Zone they are enthusiastic over the value of ipecac in the treatment of chronic amebic dysentery while in Manila they are pessimistic about curing it.

CARDIOSPHYGMOGRAPHY BY LIGHT PROJECTION

METHODS.

JAMES G. VAN ZWALUWENBURG, M. D.
Department of Medicine.

THE errors in the curves obtained by graphic registration of various cardiovascular pressure changes, introduced by the momentum of the moving parts of the instrument, have been a serious obstace to the study of these phenomena. Recently Otto Francke has substituted a pencil of light for the usual lever arm on the ordinary tambour, thereby