large cities, the greatest percentage of cases occurred in the houses of the rich situated on the heights or upper portions of the city, and in which many of the rooms were provided with the luxury of permanent marble basins, and nickel-plated exposed plumbing.

Dr. Smith cites several cases which occurred in his own practice where the relation between the bad results after confinement and operation could be clearly traced to the escape into the sick room of bacteria-laden sewer gas.

"Moreover," he says, "it is the experience of every one who has had anything to do with puerperal fever, and it is also borne out by the figures of statisticians, that this disease is much more common in winter than in summer. According to the Register General's reports, puerperal fever is at its minimum in August, when all the windows are open, and at its maximum in February, when the doors and windows are kept carefully closed."

an osteo-sarcoma of the leg, which was pounded up and a little water added. The liquor was filtered through a cloth and injected into a donkey and two dogs. No reaction followed, and five, seven and fifteen days later the animals were bled in order to collect the serum. The first case in Professor Terrier's ward was a woman who was operated on in October, 1894, for a tumor the size of an orange, dating back eight months and involv ing the sixth, seventh and eighth ribs-skin not in volved. In February, 1895, the tumor had re-appeared and attained the size of a small nut; a month later it was the size of a small orange. Treatment by serotherapy was begun March 12, injections of 3 cc. each of the serum being made in the cellular tissue around the tumor for forty days-the total amount injected being 120 cc. From March 25 the tumor manifestly dimin ished and this became more evident until at present there is to be found only an induration the limits of which are difficult to define, and the volume is not one third that of the primitive tumor. Moreover the gen. eral condition of the patient is much improved and she has gained much flesh. The second case, in the service of Professor Reclus, is that of a man 44 years of age, who entered the service on March 28, presenting a tumor in the inferior epigastric region the size of a large orange and which was diagnosed as cancer of the stom ach. Surgical interference being deemed out of the question sero therapy was begun April 6 by a preliminary injection of 4cc of serum and up to April 24 a total of 64 cc. had been injected. Improvement in the gen eral condition rapidly followed. The patient's weight, 57 kilos on April 10 had increased to 58 on the 16th and to 60 on the 23d. The tumor rapidly diminished in volume from April 10 so that by April 20 it could be no longer isolated and at present there is only the sensa tion of a deep-seated doughiness, very vague and diffi cult to outline. Our contemporary remarks that the recovery in the latter case was so rapid that it would be prudent to look upon it as an error in diagnosis.-L'ing that we have employed the most vigorous aseptic Union Med., Journ. of the Amer. Med Assn

OBSTETRICS AND GYNECOLOGY.

*

He then quotes Playfair's emphatic dictum: "Exposure to sewer gas may, I feel sure, produce the disease (puerperal fever). * * The whole question of the influence of defective sanitary conditions on the puerperal state deserves much more serious study than it has ever yet received, and I have long been satisfied that they have much to do with certain grave forms of illness in the lying in state, the origin of which can not otherwise be traced."

Dr. Smith concludes as follows: "For my own part I would much rather do a celiotomy in a wood shed or a hovel where there was no sewer or plumbing of any kind, than in the finest hospital operating room or private house where there was a direct communication with the sewer of a great city; owing to a defect in the plumbing or the syphonage of a trap.

"I would therefore lay it down as a wise rule to follow that whenever we have suppurations of our wounds or high temperatures after confinements, notwithstand

and antiseptic precautions, we should in every case suspect the plumbing until it shall have been proved inno. cent, and for this no test should be accepted as sufficient except the smoke test "-North American Practitoner.

NOTES: AND ITEMS

Professor Von Esmarch has been made an honorary member of the Academie de Medicine.

Sewer Gas and Septicemia.-Dr. A. Lapthorn Smith, of Montreal (Annals of Gynecology and Ped iatry), is very strongly of the opinion that bad plumbing is to blame in the majority of cases of puerperal fevers, and septic conditions following celiotomies where all due aseptic precautions have been taken by the physicians and nurses. He refers to the remarkable immunity from puerperal fever at the Preston Retreat in Philadelphia, and at the Sloan Maternity in New Abuse of Lunatics by Monks. - Brother York, where there is not one sewer pipe within the Heinrich, one of the monks at Mariaberg, Prussia, has buildings proper, all closets, bath rooms, sinks or basins been arrested on the charge of ill-treating the insane being situated in towers or buildings. having no connec. patients in the monastery. The exposure of the cruel tion except by galleries with the main building. He treatment of the insane has led to a demand in the has noted that in several outbreaks of diphtheria in the Prussian Landtag, that the Government take effective

measures to render such misdeeds impossible in the future, and to regulate the conduct of that and similar asylums in accordance with medical science and under complete State surveillance.

Temperance Run Mad.-There is now in Governor Morton's hands, and awaiting his approval or veto, a bill that, should it become a law, will force the pupils in every school under State control, or supported in whole or part by State money, to devote an astoundingly large part of their time to studying the nature and effects of alcoholic liquors, tobacco, opium, hasheesh, chloral, and other baleful sources of reprehensible joys. Four lessons a week on such matters are to be given for at least ten weeks a year in every grade below the second high school years, and provision is made for excluding from the schools any text-books on hygiene and physiology that do not devote at least a fifth of their pages to instruction of this kind. Regents' and other examinations must include a due proportion of ques tions about drink and drug evils, and no teacher can be licensed who has not passed a satisfactory examination in regard to his or her knowledge of them.-New York Times.

Bacteria of Graveyard Soil.-Dr. E. H. Wil son, Bacteriologist of the Brooklyn City Board of Health, has submitted a report of his investigations on fragments of coffins sent him from some of the Brook lyn suburban cemeteries. He says, in substance, that while these fragments contain, as might be expected, a large variety of bacteria, no pathogenic varieties have been found; that the popular idea that all bacteria are dangerous is a totally erroneous one. The bacteria which are engaged in the process of destructive decom. position of the body are doing a beneficent work in re turning to the soil the elements of which the body is composed, in a condition to be readily assimilated by the higher plants. Investigation has shown that the soil of graveyards contain no more bacteria in propor tion than the soil of other places, especially below a eertain depth. "In conclusion, I would say that while. the presence of coffin fragments several years old is not to be commended from a bacteriologic point of view they are comparatively harmless, and only remind us more forcibly of the fact that it is the living and not the dead from whom we may expect harm in this matter."-Jour. Am. Med. Ass'n.

had smoked twenty-five pipes on a wager, who suffered for many months with vertigo. The vertigo of chronic intoxication from tobacco, he said, might be observed in the workmen and work-women in tobacco factories, as well as in smokers, in snuff takers, and in those who chewed tobacco. The action of nicotine varied accord ing to the amount absorbed, and the disturbances caused in the life of the cells in consequence of their contact with the poison might also be variable.

M. Le Roy de Mericourt remarked that he had never observed smoker's vertigo in Brittany or in certain other countries in which he had lived for a long time, but he had observed a tendency to syncope dependent upon disturbances of the circulation following intoxication with the ordinary tobacco.-New York Med. Journ.

Heroism of Medical Officers in the Chinese War.-An item which must excite admiration is reported by a correspondent at Wei-hai-wei in the current number of the Broad Arrow: "Now came a touching proof of heroic devotion to duty. While the storm of lead was still hurling thickly through the air, a company of Red Cross men, always well to the front, appeared on the field, stolidly marching out from the ravines, two and two, with stretchers and 'first aid' appliances for their comrades, right under the withering fire from the gun-boat, with never a moment's hesita tion. Unarmed, but for a paltry dirk at the side, helpless in any case against such an attack, with foes heedless or ignorant of the sacred significance of the Red Cross badge, they did not flinch for a moment on their errand of mercy. It would have been easy to wait until the fire should cease, but they nobly went on and did their work as if on their parade ground at home. One by one the dead and wounded were sought all over that wide field of blood, and borne away, until within twenty minutes the place was completely cleared of every man, living or dead. Colonel Taylor, A.M.S., declared it the most splendid deed he ever saw, and the other foreign attaches who saw it were equally emphatic in their praise.”

To the Rescue of Oysters.-After all the recent abuse of that "child of the rock and of the hoary sea," the oyster, as an infection carrier and as a "scavenger of the sea" it will be consoling next September to recall the good words spoken for the bivalve at a recent seance of the Paris Academy of Medicine. M. Chatin stated that for some time he had pointed out the Smoker's Vertigo.—At a recent meeting of the richness of oysters in bromin, iodin and fluorin. He Congres des societes savantes, a report of which appeared wished now to make known the great quantity of phosin the Progres Medical for May 4th, M. Kohos said that phorus which oysters contained in an organic and, convertigo caused by nicotine was very frequently observed, sequently, assimilable combination. The Portuguese and that it manifested itself sometimes under the form oysters are the richest of all in phosphorus. Each of of a slight acute poisoning accompanied with pallor, them contains very nearly one-twelfth of a grain of salivation, cold sweats, headache, vertigo, staggering, phosphorus; ordinary oysters have about one-third of etc., which symptoms were produced in those who this amount. These mollusks are equally rich in iron, smoked for the first time; sometimes the poisoning was their brown color being due to diatoms. A great num. more serious, as, for instance, in the case of a man who ber of infusoria on which the oysters feed are filled

with these diatoms which are so rich in iron that the antipyrine and in three or four days the patients had ash from burning them is of a deep red color. M. Gau recovered. M. Queirel said that he had observed par. tier remarked that all sea food is very rich in phospho- ticular syndromes. In certain cases there had seemed rus in the organic state; thus cod liver oil contains to be an outbreak of small-pox; in others, angina, etc., phospho glyceric acid besides its alkaloid. M. Le Roy but there had never been anything observed affecting Mericourt stated that he had a long time ago indicated the genital organs -New York Med. Jour.

the service rendered by oysters in the alimentation of

Many interesting papers were read. The meeting was one of the most successful yet held. One of the interesting features of the meeting was the presentation of a silver shield suitably inscribed to the founder of the organization, Prof. Nicholas Senn, at present Surgeon-General of the Illinois National Guard.

The Military Surgeons.-The National Assopersons attacked with chronic diarrhea in tropical counciation of Military Surgeons met in Buffalo, May 21. tries-Le Bull. Med; Jour. Am. Med. Ass'n. Brigadier General George M. Sternberg, U. S. Army, presided. Mayor Edgar B. Jewett welcomed the AsThe Treatment of Burns with Thiol.sociation in the name of the city of Buffalo, and the In the May number of La Clinique there is an article President of the State Medical Society, Roswell Park, on this subject in which the writer says that according M.D., in behalf of the profession. Responses were to A. Bilder, of Berlin, thiol is one of the best appli- made by General Sternberg and Major Briggs. cations in the treatment of burns of all degrees. Bilder first washes the burned part with a weak solution of corrosive sublimate and then removes the cuticle hang ing loose as the remnants of ruptured blisters, taking care not to touch those of which the walls are still in tack. After dusting the burns with powdered boric acid, the entire surface of the burned region and the healthy skin around it are painted with a solution of equal parts of thiol and water; finally, a layer of greased cotton is laid on the burn and kept in place with a bandage. Thiol allays the pain very rapidly and arrests the hyperemia of the skin. Part of the contents of the blisters is absorbed and the rest becomes dry in the form of semi-transparent, amber colored crusts which are easily detached, leaving a completely healthy skin. At the end of eight days the dressing is removed. Secretary-Eustathius Chancellor, Lieutenant-Colonel The rapidity of the cure varies according to the degree and Medical Director, N. G., Missouri. of the burn. In burns of the first and second degrees it is generally rapid. In those of the third degree the N. G, Ohio. cicatrices which are formed under the dressing of thiol are smooth and show no tendency to retraction.-New York Med. Jour.

Grippe in Puerperal Condition.-At a re cent meeting of the Congres de la Society Obstetricale de France, a report of which appears in the Prog. Med. for May 25, M. Queirel, of Marseilles, reported thirtyfive cases of grippe occurring in puerperal women. In all the cases there had been pulmonary localization, and in two broncho pneumonia. No deaths had occurred. Eleven of the women had been confined before term, and the others at term. The membranes had been rup tured four times during the efforts made in coughing. One patient who had undergone symphysiotomy, had been attacked with pneumonia during her lying-in; an other had had gastric symptoms and her child had had erysipelas. There had not been a single case of suppu

ration. M. Queirel had used corrosive sublimate for vaginal and uterine injections, but he did not practise the uterine injections unless the temperature rose. Perhaps it was owing to this procedure that no cases of infection had occurred.

M. Gaulard had also had an epidemic of grippe in his clinic at Lille; but, he said, he had taken no particular care in regard to the genital organs; he had simply used

Philadelphia was selected as the next place of meeting and the following were elected as officers for the ensuing year:

President-Louis W. Reed, Colonel and SurgeonGeneral, N. G., Pennsylvania.

First Vice-President-Albert L. Gihon, Medical Di rector U. S. Navy.

Second Vice-President-Col. Charles H. Alden, U. S. A

Treasurer-Lawrence C. Carr, Major and Surgeon,

The Denver & Rio Grand Railroad is the most direct route from Denver to Ogden, running as it does, through the most picturesque and mountainous country of Colorado. There is perhaps no part of the United States where there is greater attraction for the

tourist.

The climate is unexcelled for invalids, cool and brac

ing in summer, warm and exhilirating in winter.

On this line of road are found many Medicinal Springs, the waters of which are highly recommended by physicians and which are indicated in many of the diseases man is heir to.

It is unnecessary for us to state anything of the equipments of this road, other than that they are of the most modern, which will conduce to the comfort and pleasure of the traveling public.

The 26th Triennial Conclave Knights Templar will be held in Boston, Mass., August 26 to 30, 1895. For this occasion the Wabash Railroad will sell tickets from all stations to Boston at one fare for the round trop. Map of route and guide to Boston will be mailed on application to

C. S. CRANE,

General Passenger and Ticket Agent, St. Louis, Mo.

The Pathology of Tubercular Arthritis. amongst the embryonic cells. These are the giant cells

BY J. F. BINNIE, C.M., KANSAS CITY, MO.

Read before the meeting of the State Medical Association of Missouri,
Hannibal, May 21-24, 1895.

Tubercular arthritis is the same disease whether primarily synovial or osteal.

and are also found in certain sarcomata and in normal granulation tissue.

Whenever any irritant is present in the tissues, leucocytes take part in the reaction of the organism to insult, hence around and amongst the cells already spoken of white blood corpuscles congregate. We now have all the cellular elements which make up the typical tubercle, The classification of the forms of tubercular arthritis, viz, giant cells; epithelioid cells; small round cells and though interesting and extremely useful from a thera- leucocytes. In such a tubercle the bacilli are to be peutic standpoint, is liable to confuse the practitioner found enclosed in the giant or epithelioid cells or lying who has not made a careful and somewhat extensive between them. study of the disease. He is liable to lose his way amongst the various minute named subdivisions of the pathological lesions. He forgets that all these lesions are essentially the same, one being distinguished from the other merely by the effects of accidental differences in their surroundings and of the influences brought to

bear on them.

In opening a discussion on the pathology of tubercular arthritis my aim will be to emphasize the unity of

the disease.

PATHOLOGICAL ANATOMY AND HISTOGENESIS.

The tubercle, the histogenesis of which has just been briefly described, is about the size of a millet seed, of a pale gray color and is somewhat hard. It is named "miliary tubercle." The classification of tubercles as miliary, crude, granular and encysted is to-day useless as we now know them all to be forms of one and the same process.

For the sake of clearness we have here described the

growth and structure of a very small tubercular lesion. These small tubercles may coalesce and form larger masses. The irritation produced by the bacilli is not necessarily confined to their immediate vicinity. Some 1. In soft structures.-As the result of an irritation of the more diffusible of the bacillary products may produced by the presence of tubercle bacilli or their cause a formation of granulation tissue not necessarily ptomaines, the tissues which this irritation affects un-infected by the bacilli themselves. In chronic tubercudergo changes similar to those which take place in the lar lesions large masses of this tissue may be formed healing of wounds by granulation. The tissue elements which shows but little tendency to develop. become embryonic and devote their energies to the reproduction of their species. For example, the connec tive tissue corpuscle no longer forms those fibres of protoplasm which are characteristic of mature connec tive tissue, it merely divides and out of one round cell forms two, these two in their turn taking up the work of division.

Thus in a short time a little mass of round cells is formed, indistinguishable, so far as the cells are concerned, from the cellular elements of a round cell sarcoma or of the very early stages of a wound healing by granulation.

Throughout such masses, it is common to find a large number of small nodules or tubercles scattered. While the tubercles themselves are non-vascular the masses of granulation tissue in their neighborhood are well supplied with blood vessels. These vessels often undergo changes. The intima becomes thickened, fibrous and markedly diminishes the lumen of the vessel. At the same time the adventitia shows similar changes. Ziegler names this process "hyperplastic arthritis."

II. In bone.-Bone being merely a mesoblastic tis sue in which certain inorganic elements are deposited giving it hardness, we would naturally suppose the his

togenesis of tuberculosis in it to be the same as else may take the form of great proliferation of the conwhere. The supposition is correct. As a result of innective tissue elements of the synovialis. In this form fection, the connective tissue of the medulla undergoes of the disease there is very little if any effusion of fluid the same changes as in other locations and a mass of granulation tissue is formed, which causes absorption of bone so that in a macerated preparation we find evidences of former tubercular foci in the presence of cavities varying in size according to the extent of the dis

ease.

An infected embolus may be carried into the vessels of the epiphysis of a bone and shut off the circulation from a limited area. The result of this is necrosis.

The tendency of Nature is always to surround a piece of dead bone with a layer of granulation tissue. Here the granulation tissue formed is at once infected from the embolus which originated the trouble.

Thus we see that the lesion in bone is structurally practically identical with the lesion in soft parts.

into the articular cavity. This great class of cases has been divided into certain subdivisions.

a. Parenchymatous synovial tuberculosis (Krause). The synovialis becomes much thickened and contains innumerable miliary tubercles which are pale in color and contrast markedly with the red congested synovial membrane.

b. Solitary tubercles of the joint (Koenig). Only a part of the synovialis may be diseased, the new formed tissue taking the form of masses of fibrous tissue infiltrated with tubercular nodules. According to the richness with which these connective tissue neoplasms are infiltrated with tubercles careation becomes a more or less marked feature. These solitary tubercles vary in size from a pea to a pigeon's egg.

C.

Villous form. The whole synovial membrane HOW CAN THE BONE LESION GIVE RISE TO ARTHRITIS? may be covered with villous like growths on which I. A tubercular focus situated in an epiphysis may fibrin is deposited and organized. As these are readily give rise to an arthritis which is primarily non tubercu broken off from their attachments they may form free lar and which may even run its whole course without bodies in the joint. This is an uncommon form of the becoming specific. The mere presence of a tubercular disease. As a rule such oryzoid bodies are found in focus near a joint is sufficient, under favorable circum- joints in which there is much effusion. stances, to set up a reactive inflammation in the joint d. Caries Sicca (Volkmann). The granulation tissimilar to the evanescent synovitis resulting from a sue may spread over the ends of the bone destroying slight trauma. This affection is at first characterized the cartilages and the superficial layers of the bone. merely by the presence of fluid in the joint and may e This tissue may even penetrate the deeper layers of the solve at this stage. If, however, resolution does not bone, undermine a superficial portion of it and throw it occur the synovialis swells, becomes transformed into off into the joint as a foreign body. simple (non-tubercular) granulation tissue which in time may fill up all the synovial cavity and when it becomes fully developed fibrous tissue the whole joint cavity is obliterated except such of it as lies opposite the cartilage covered ends of the bone. The simple granulation tissue may even spread over the cartilage and destroy it so that not a vestige of joint cavity is left, the granulation tissue between the ends of the bone being converted into fibrous tissue or bone, result ing in fibrous or bony ankylosis.

II. The osteal tubercular focus may, by the erosion of the bone, open into the joint and so give rise to tu bercular arthritis. If the joint has undergone such changes as have been mentioned as being the result of reactive inflammation, this accident may be of little moment the synovial cavity being to a greater or less extent obliterated. If, however, the osteal focus opens into a joint otherwise healthy, infective matter is spread all over the synovialis, a most favorable soil, and ac cording to Krause, in about three weeks that membrane presents all the peculiarities of structure characteristic of tuberculosis. In children the local disease is frequently primarily synovial, the infection being derived from pre-existing pulmonary or intestinal lesions.

B. The second course which synovial tuberculosis tends to follow is one characterized by caseation, exudation and suppuration,

The synovial membrane is as a rule but little thickened but the joint cavity contains fluid. According to the nature of the articular contents these cases naturally group themselves into classes.

a. Hydrops articuli tuberculosus (Koenig). Here the joint is filled with almost pure serum and may aptly be compared to a hydrocele (remembering, of course, that the one is specific and the other not). As in hydrocele so here also we may have a deposition of fibrin on the endothelial lining of the sac and over the articular cartilages. It is easy to understand how this fibrin deposit when covering a villus with many layers and becoming organized can and does form the aryzoid bodies already referred to. It is in this class of cases that these bodies are most common. The joint cavity may be full of them. If the fibriu spread over the articular cartilages and is infiltrated to a great extent with fibroblasts it becomes to all intents a granulation tissue and so can absorb the cartilage and superficial layers of the bone, producing caries.

An accident of frequent occurrence in hydrocele is hemorrhage which so alters the contained fluid that a new name is given the affection, viz., hematocele. A similar accident is of frequent occurrence in hydrops A. The reaction of the tissues to the specific poison articuli tuberculosus so that a hemarthros is produced.

III. Synovial tuberculosis whether primary or sec ondary to osteal disease may follow one of two courses in its later history.