for it is entirely too much of a heart depressant. He also favored having the baths given under the direction of a resident, and believed that the heart was so much depressed by the baths that they should not be given except in the presence of a physician.

Dr. I. E. Atkinson of Baltimore said that in children most cases of typhoid fever were atypical and hence the great difficulty of diagnosis. But as soon as we reach the stage where we can eliminate other diseases and have a continuous fever we can be pretty sure of typhoid, and most mild cases can best be treated by letting them alone and simply nourishing and stimulating the patient. But in adults and when the temperature runs high in children he strongly advises the Brandt method.

Dr. J. A. Larrabee of Louisville, Ky., said he believed the small number of cases of typhoid in children in hospital practice was due to the hygienic surroundings.

Dr. Burr of Chicago urged the early application of the Brandt treatment, as acting by nerve stimulation. He also urged the profession not to treat the temperature as a disease, but to treat the specific poison.

Dr. S. S. Cohen of Philadelphia said he entirely agreed with the sentiment of Dr. Burr and warmly advocated the application of the Brandt method as diminishing the intensity of the cerebral symptoms and doing an immense amount of good, but that he also believed there were many cases in which medication would do a deal of good and believed that between Scylla and Charybdis we could steer a straight course between medication and the Brandt method. He also advocated the giving of alcoholic stimulants before and after the bath.

SECTION ON THE PRACTICE OF
MEDICINE.

SECOND DAY, WEDNESDAY, MAY 8. Dr. Frank S. Parsons read a paper entitled Some Points concerning the Etiology of Tuberculosis, in which he claimed that the germ cause of the disease was quite secondary in its influence

and pre-tuberculous condition is necessary for the disease to start. Tuberculosis is more a symptom of lymphatic disturbance than a disease. In looking at the cause of this disease we should not forget the chemical composition of the body.

Dr. De Lancey Rochester of Buffalo then read a paper on Tuberculosis Treatment by the method of Carasso, which is much like the old creosote and alcohol treatment, with the addition of peppermint. Peppermint is inhaled and taken internally. He found that the internal administration was useless and disturbs the digestion, but the inhalation was valuable.

Dr. Delano Ames of Baltimore has used Carasso's method in ninety cases with improvement in two cases which might have been due to other causes. He approved of their inhalation.

Dr. Denison of Denver said that with our present knowledge the climatic treatment was the best.

Dr. Karl Von Ruck believes tuberculosis of the lymphatics preceded tuberculosis of the lungs.

Dr. Parsons of Chicago thought that in catarrh of the stomach which so often accompanied tuberculosis creosote was contraindicated.

Dr. Rochester did not believe in the pre-tuberculous condition, nor did he believe in hereditary tuberculosis. He believes in the gradually increasing doses of creosote and if it disagrees in water it may be given in wine or mucilage.

Dr. Paul Paquin of St. Louis read a paper on the Treatment of Tuberculosis with Horse-Serum Injections. Tuberculosis exists in various regions of the body long before it gives any external symptoms. A patient may suffer pulmonary infection from his own glands rather than from outside sources. We are therefore unable to make a positive diagnosis until after internal organs have become involved for the commencing appearance of bacilli in the sputa is unfortunately not a sign of incipient tuberculosis, but rather of a distinctly progressive grade of the tubercular proIn January of the present year,

cess.

the author reported to the St. Louis Medical Society the results of the treatment of twenty-two cases treated with horse-serum. The patient received one injection below and outside of the scapula daily for an average of two months. All improved and gained in weight, the gain being from one and one-half to twenty pounds in the course of the eight weeks of observation, and all are now living. They represented all grades of the disease from infiltration up to cavity formation, all presented bacilli, and all were distinctly emaciated. Several had had hemorrhages. Of a few additional cases since treated, two had died in from three to five days after the treatment was begun, but they were hopeless when first seen. Absolutely no other treatment had been employed in all the cases. When the serum was stopped they grew worse, but re-improved upon its resumption. The remedy seemed to diminish all the evidences of tubercular activity. Hemorrhages were arrested, appetite improved, cough lessened and the nervous irritability quieted. The remedy also seemed to promise good results in surgical tuberculosis. In one case of knee-joint disease, removal of the diseased structures had been followed by serum injections with good results. As regards the production of the serum, horses were naturally immune to tubercular processes. First of all, an injection is made of some culture media containing the toxines of the bacilli into the jugular vein; when the animal ceases to react to this dead bacilli are injected, and finally living bacilli, when all reaction has subsided, blood is withdrawn from the vein placed on ice, and the serum gradually allowed to separate. It is then filtered and is ready for use.

It has been found that serum from a given animal varies in power after successive withdrawal from the vessels. Hence there is a variation in the effects of serum from the same animal upon patients. After awhile, the animal seems to develop certain toxines during the recuperation from the debilitating effects of the bleedings. TransportaTransportation seems to harm the serum, as various germs are apt to develop therein.

We

must not tap the horse too early after immunization as, under these conditions, the serum dose not seem to possess its maximum curative power. From ten to thirty minims are used for each injections, and camphor has been found to materially assist in keeping the serum in good condition. After the injection it has been observed that the face flushes and gradually becomes purplish for a period of four to five minutes, and a slight chill frequently follows. This dose not always happen, and when it does occur it is probably to be explained by the fact that the needle has been thrust directly into a blood vessel instead of into the cellular tissues. Arthritic pains have been observed especially with patients who have previously been rheumatic. The urine is considerably diminished and albuminuria has been observed in one case.

Dr. Karl von Ruck doubted whether any animal could be regarded as absolutely immune toward tuberculosis. To prove the position taken by Dr. Paquin we ought to kill the animal and make careful pathological and bacteriological examination of its tissues. Our animal experimentation was not yet complete, and there was no proof that the serum had any power on either animals or men. Dr. von Ruck had tried Paquin's serum on guinea-pigs and all had died within forty-eight hours. Granted, moreover, that the serum had effects on the bacilli, it was impossible to remove the results of tissue change which come from the condition of mixed infection, which we so frequently find in ordinary phthisical cases. Insistance should be laid on the importance of early diagnosis from the clinical history and physical signs alone, for when we find bacilli it means that suppuration or tissue degeneration have already occurred. We should use tuberculin for its diagnostic value. The reader of the paper had spoken of the spores of tubercle bacilli. He (Dr. Von Ruck) had never seen them, and moreover it was a matter of doubt whether this variety of germ had really true spores or not.

Dr. De Lancey Rochester of Buffalo called attention to the fact that many

cases of phthisis recover without any treatment at all, and he could not believe that specific treatment had any place in cases of mixed infections.

Dr. Henry D. Holton of Vermont stated that the serum of the ass would probably be superior to that of the horse, as there was little mortality from phthisis in those countries where the milk of the ass was used. The juice from the muscle of animals in whose muscles no tubercles are found, but who have tubercle elsewhere, has been found to produce the disease; also milk from cows who, though tuberculous, have healthy udders, and no bacilli in their milk.

Dr. Paquin, in closing the discussion, admitted that the serum might occasionally contain some cocci, but that they were not necessarily harmful. The same was the case with Behring's serum and yet everybody used it. As to spores, he believed that he had seen them, as they gave the stain reactions of tubercle bacilli. The blood of asses he had no experience with. Mule serum seemed to be the same as horse serum, but he did not deem it prudent to use it, as the former animals are very subject to a disease resembling rheumatism in man.

Dr. N. S. Davis, Jr., of Chicago, read a paper on A Case of Pulmonary Hypertrophic Osteo-Arthropathy. Cases had been reported. It had to be distinguished from acromegalia. The essential lesion seemed to be chronic multiple osteitis of the terminal phalanges and the ends of the long bones. The cause of the osteitis was probably some poison absorbed from the lungs or pleurae. Cases had also been observed in connection with congenital heart disease, syphilis and spinal caries, but in general the association was with suppurative diseases in the respiration tract.

Some regarded it as an attenuated tuberculosis; others as a trophic nerve affection; still others as due to caries of the spine, while, as above suggested, three cases had been observed in syphilitic disease. No heart or lung disease was evident in these latter, but in the spleen and liver, four cases, bacilli were found. Pulmonary hypertrophic osteoarthropathy therefore was rather a symp

It

tom group and not a disease per se. was probably a toxemia from the respiratory tract. The case was that of a boy aged about four, with cough and periodical expectoration of pus, dating back to a pneumonia one year before. There was an enlargement of the fingers, toes and wrists and curling of the nails. The skin and glands seemed normal and the body was well nourished. There was no kyphosis or scoliosis. On the left side of the chest there was a bulging and immobility in respiration with dullness and displacement of the heart to the right, in fact, all the symptoms of a pleural exudate compressing the lung. It was believed to be prevalent and the purulent sputa were probable periodical drainings off of the exudate through a bronchus. At such times there was fever with the usual pus reaction. The symmetry of the bone and joint lesions was a feature of the disease. In previous cases the urine had been reported as normal. As to a diagnosis from acromegalia, the latter, it should be remembered, was chronic. The enlargement of the fingers was uniform. The kyphosis when present was cervico-dorsal, in the arthropathy dorso-lumbar. The seat of the lesion in acromegalia was the pituitary body, and there were generally visual disturbances.

Dr. S. Solis-Cohen of Philadelphia stated that he had seen two cases which might fairly come under this category. In acromegaly the hand was broadened as a whole while here it seemed lengthened. ened. Kyphosis was frequently present in tuberculosis and with his present knowledge he was inclined to regard the arthropathy merely as an exaggeration of what we commonly see in tubercular disease. The wrist and ankle enlargements are suggestive as in acromegaly; these two joints are not involved. The trophic disturbances apparently led to the development of certain structures at the expense of others, and they were probably due to some pus toxine.

Dr. H. B. Sears of Beaver Dam, Wis., read a paper entitled Measures Calculated to Modify Acute Inflammation of the Respiratory Tract. The majority of deaths in acute respiratory diseases oc

cur from excess of its mucous secretions or from heart failure. This is especially true in the case of spare people poorly nourished, whose nutrition was principally at fault, and stout people with more or less cyanosis, rapid pulse and breathing and complaining greatly of thirst. In both there was feeble heart action with a resultant overloading of the veins and capillaries. A great mistake was frequently made in giving too much fluid to these patients. Heart stimulants alone were of limited applicability as we would not over-force a debilitated organ. We should first purge freely so as to relieve vascular overloading and then give heart stimulants. The excess of secretion should be combated by belladonna and turpentine. For a heart stimulant. For a heart stimulant digitalis was useless in high temperature as it was not absorbed. With the plan above outlined anodynes and antipyretics are more rapidly absorbed.

Dr. A. H. Burr of Chicago read a paper on Hydrotherapy in Fevers; its Rationale and Technique; in which he gave a general description of the febrile state, setting forth that the high temperature is the result of a toxic derangement of normal resistance to and normal control of the heat-making apparatus of the body. Too much effort had been made merely to reduce the temperature in febrile conditions. The numerous coal-tar derivatives marked the height of this craze. In the application of the cold bath, we should always bear in mind the physiological action of water. It is a neutral stimulant; it affects the sympathetic nervous system and thereby exercises a direct control over the glandular system; by its reflex action, it had a marked influence upon circulation, respiration, metabolism, elimination and pyrexia. Winternitz has shown that after a cold bath there is increased leucocytosis, increased hemoglobin and increased specific gravity of the blood. Thayer had shown similar results in examining a drop of blood taken from the ear of a patient who had received cold baths. The increased leucocytosis was too marked to be explained by cell proliferation. It was probably due to the fact that the increased circulatory ac

tivity swept out into the general current the cells which had become lodged in the various corners of the vascular system. Dr. Burr then exhibited a wooden frame to be placed on the bed for bathing febrile cases. Under the patient was slipped a rubber sheet which had tapes on its sides. These were brought up over the frame and fastened thereto so that a tub was improvised capable of holding twenty gallons of water which after use could easily be syphoned out. The whole apparatus was portable and easily manipulated.

Dr. N. S. Davis, Jr., of Chicago did not believe that bathing shortened the course of fevers but it did lessen danger and made the patient more comfortable. A rise of temperature meant toxic absorption. The so-called typhoid state was found in other diseases than typhoid fever. It meant perverted metabolism and we should remember that we are treating this state rather than one of infection.

Dr. Boylan of Pittsburg, Pa., insisted upon the importance of keeping the skin thoroughly clean in all febrile states and this is one of the good effects of the bath. He declared that death would result in three hours if the respiratory function (so-called) of the skin was completely checked.

Dr. Webster of Chicago doubted the truth of this last statement. Death had ensued in animals whose skins had been coated with a varnish or similar substance, but it had been due to loss of heat. If the varnished animals were enveloped in cotton or their external heat kept up, they did not die.

Dr. Charles G. Stockton of Buffalo heartily endorsed the position taken by the reader of the paper and made a plea for the use of the bath in small communities.

Dr. S. Solis-Cohen thought that any sheet arrangement is disadvantageous in that it brings merely small pools of water in contact with the patient. The good effect of immersion was thereby lost.

Dr. Burr's device was doubtless next in utility to a tub.

Dr. F. B. Turck of Chicago believed in baths of water at 95° raised to 115° or

until there was marked dilatation of the superficial vessels. Then the patient should be rubbed down with ice, and cold water applied in douches with the syphon. In conditions of passive congestion such a procedure would restore the equilibrium of its circulation.

Dr. De Lancey Rochester of Buffalo insisted that the most important thing in bathing was the continuance of gentle friction over the body during the entire immersion. The water was more important as a nerve tonic than as an antipyretic.

Dr. James Tyson of Philadelphia said that most of the cases which had died during his practice under bathing had succumbed to perforation or hemorrhage. He is a firm believer in the bath.

Dr. J. M. Anders of Philadelphia, while an advocate of bathing, believed that there were contra-indications thereto. As soon as intestinal hemorrhage occurred he stopped the bathing for awhile.

Dr. Burr, in closing the discussion, said that he believed that the Brandt method, while not curative in every case, did nevertheless alter the entire aspect of typhoid fever for the better. He believed that the profession in America was culpably negligent in not using it more generally.

Dr. James Tyson of Philadelphia read a paper on the Symptomatology of Irregular or Atypical Gout. His object was to insist upon accuracy in nomenclature. He alluded to the recent views of Garrod and Roberts to the effect that the causative uric acid existed in the blood in the form of a quadriurate of sodium. There was no difficulty in diagnosticating typical frank gout but there. was after-trouble with the incomplete form. Among the atypical gouty manifestations noted are dyspepsia, deposits of lithiates in the urine, eczemas, muscular pains, deep seated pain in the tongue, crackling feeling about the cervical spine, pains in the back of the neck and loins, adductions of the thigh and gastrocnemius, also articular pains in the nodosities, headache, pains in the palms of the hands, folliculitis of the nose, scleritis, keratitis, conjunctivitis, asth

ma, bronchitis, tonsillitis, pharyngitis, dryness of the tongue, also inflammations of the bladder and hemorrhages there. There was also a cerebral gout, characterized by a capriciousness, melancholy, insomnia and changes of temper. He laid especial stress upon the importance of recognizing a possible gouty cause in cases of vesical hemorrhage. He would, in the diagnosis of a suspected case, lay special stress upon the following points: 1. A condition of uricacidemia but it was rarely possible to diagnose uric acid in the urine. with the means in the hands of the general practitioner. 2. The supervention of the regular gout on the subsidence of other ailments or alterations between the two clinical conditions. 3. The history of previous gouty attacks. 4. Heredity. 5. A history of exposure to lead poisoning. 6. The general habits and mode of life of the patient. 7. Scanty and highly colored urine. This might also occur in lithemia. 8. Glycosuria. 9. Chronic interstitial nephritis, which was the fatal goal toward which all these other symptoms invariably led. IO. The result of therapeutic agents usually thought to be of benefit in gout.

MEDICAL PROGRESS.

COAL-TAR.-The use of coal-tar, says Leistikold, in the American Medico-Surgical Bulletin, as a substitute for the oil of cade, ol. fagi, or ol. rusci is here advocated, on account of its cheapness and efficiency. Its disagreeable smell is partly covered by putting it up with alcohol and ether, the best formula being 3 parts of coal-tar, 2 parts of alcohol (95 per cent.), and 1 part of sulphuric ether. This is to be applied by means of a brush, and it at once dries on the skin. In 200 cases it caused folliculitis in 12 patients, and systemic symptoms in one. It has marked antipruritic qualities, but can be used only on limited regions. It is indicated in dry eczemas, psoriasis (specially combined with 2 per cent. chrysarobin), prurigo Hebrae, and trichophytosis.