and still many of these cases present no constitutional symptoms and are not followed by the usual sequelae of diphtheria. I have two such cases under my care at this time and cannot bring myself to look upon them as true diphtheria. DR. A. E. CARRIER: If you give a perfectly reliable preparation of calcium sulphide, one-fourth grain to one-eighth grain seems to be too large a dose not to be followed by unpleasant gastric symptoms. If a good fresh preparation of Merck's salt be given the desirable results may be obtained from one-hundredth grain.

DR. R. A. JAMIESON: I have employed benzoate of soda in these cases with success, giving ten grains every two hours, and with it use a benzoate of soda spray in the throat every half hour. This line of treatment is much more efficient than chlorate of potash and tincture of iron treatment, which latter is very liable to produce gastric disturbance, which, however, is not the case with the benzoate of soda treatment.

DR. H. J. HARTZ: Experiments on animals prove that a croupous membrane can be produced by trauma, chemical gases, and caustics. In diphtheria the bacteria produce a croupous membrane so that late authorities divide the disease into two varieties: (1) The mild croupous with but little systemic infection, and (2) the severe or septic form followed usually by fever and paralysis. Diphtheria could be successfully treated locally by remedies suggested two or three months ago by Dr. Jennings, but we should be called early enough and apply the remedies thoroughly ourselves.

DR. CARRIER: There seems to be but little difference to the outcome of the case we look upon this affection as one or two diseases. All suspicious cases should be isolated and treated as diphtheria. The diagnosis by bacteriological method is not practicable to the busy practitioner.

DR. WILSON: An abrasion or a trauma may make a favorable nidus for the infection of the diphtheritic poison.

STATED MEETING, NOVEMBER 24, 1891.

THE PRESIDENT, GEORGE W. STONER, M. D., IN THE CHAIR.

DISCUSSION OF PAPERS.

DR. J. P. O'DWYER read a paper entitled "Intubation of the Larynx." (See page 9.)

DR. C. G. JENNINGS: Dr. O'Dwyer, in his paper, has made the assertion that intubation has not been duly countenanced and properly tried by the surgeons of Detroit. To this assertion I must most emphatically take exception, because we are using intubation in Detroit and have been for some considerable time. In my own practice, I cannot get as good results in laryngeal diphtheria from intubation as I can from tracheotomy. This is due to one of two causes: either I do not grasp the essentials of the operation, or the type of cases I meet with are different from that met with by other men. There is one peculiar thing about the operations, and that is that some men seem to get fully better results from one form of operation than they do from the other. Some make brilliant records with tracheotomy and his neighbor makes equally brilliant results with intubation. My own best results come from tracheotomy. It seems to me that the Doctor's assertion that perfect tubes are very essential is not absolutely true,

because when intubation first came into vogue, the records show very brilliant results, but the tubes were necessarily very imperfect in their construction. These records have not improved in like proportion to the alleged improvement in the construction of the tubes, but still the fact remains, that the more perfectly the tube fits the larynx, the more comfortable the patient is and the less likelihood there is of ulceration. To illustrate my experience with intubation and tracheotomy, I will give the following cases somewhat in detail: (1) A case of mild, pharyngeal diphtheria, which gradually implicated the larynx. Intubation was performed and very great difficulty was encountered in feeding the child; this was finally overcome by forced feeding. The membrane re-formed below the tube and great difficulty was found in keeping the tube free; his breathing was continuously embarrassed and he finally died on the seventh or eighth day. (2) This case was similar to, but more severe than, the above. I performed tracheotomy. There was the same condition of the extension of the membrane down into the trachea, but we had no difficulty in keeping the passage free, the membrane being quite easily reached through the tracheotomy incision; this case made a good recovery. I firmly believe that had this case been intubated it would have ended fatally. Many cases end fatally after intubation. Any man who has a good knowledge of the anatomy of the parts, can easily introduce the tube after he has tried it a few times and operation on the cadaver is not a necessity.

DR. H. O. WALKER: Does the performance of intubation militate against a subsequent tracheotomy?

DR. C. G. JENNINGS: Secondary operations are not very successful. There should be a limit after intubation for the performance of secondary tracheotomy. After tracheotomy the throat can be thoroughly and antiseptically cleansed, and it is put in a position for the greatest amount of physiological rest, much more so than after intubation, for the tube always acts somewhat as a foreign body.

DR. H. O. WALKER: Could the larynx not be antiseptically dressed after tracheotomy?

DR. C. G. JENNINGS: It could.

DR. STANLEY G. MINER: As to simplicity of intubation, it is not so very simple as one at first glance might think. Some cases are very difficult of introduction, the false membrane getting in front of the tube and preventing its easy introduction. It is very necessary, for complete success, to observe carefully all the details of the introduction. The position should be perpendicular, inclining slightly forward, as this is the best position for an easy introduction of the tube. When once thoroughly mastered its apparent simplicity, and the fact that parents and friends will more readily consent to it, is the chief advantage over tracheotomy, which holds out more horrors to the eyes of the parents and friends but this very fact interferes very materially with the value and accuracy of statistics on these two procedures, because tracheotomy will frequently not be allowed until the patient is very far gone. Intubation has not yet reached the highest point of its utility. We should be careful in selecting our case for intubation because once the tube is in all other medication must practically stop. Thirty minutes at least must elapse before we are sure that the tube will remain in the larynx. I do not think intubation is indicated until the voice is materially interfered with; the patient shows signs of cyanosis

and then a retraction of the chest walls. Up to this point medication-general and local-should be vigorously employed. Respiration is, as a rule, much better after tracheotomy than after intubation and the patient can, with greater safety, be left with its nurse; the parts can be more thoroughly and easily treated and cleaned antiseptically. My tubes have always been of the ordinary make and I have had no trouble referable to imperfection in their design or construction.

DR. J. P. O'DWYER: I thank the gentlemen for the complimentary way in which they have discussed my paper. That there are disadvantages cannot be denied, but I think the disadvantages are outweighed by the advantages which it presents. The tube will sometimes be coughed up and will have to be replaced, and any accumulated discharge or membrane will have to be removed. Fifteen to forty grains of sublimed calomel every two hours will liquefy the discharge and render it much more easily removed. I have used the tube in whooping-cough. DR. STONER: Have you used intubation with success in whooping-cough? Theoretically it would appear to be a bad thing.

DR. O'DWYER: Yes; I have used it with success in whooping-cough. Many cases go on to recovery after its use without cough and no bad results have followed its use. DON. M. CAMPBELL, Secretary.

CORRESPONDENCE.

LONDON LETTER.

TO THE EDITOR OF The Physician and Surgeon:-The year 1891 can hardly be said to have been a sensational one, as far as medicine is concerned, in this country. We have had no sensational announcements such as the discovery of Koch's tuberculin, which set all the world talking last year.

KOCH'S TUBERCULIN.

Given to us near the close of 1890 with a flourish of trumpets and with puffing ad nauseam, that mysterious and deadly compound seems now to be almost forgotten, though perhaps the careful researches of Watson, Cheyne, Hunter, Crookshank and numerous other observers may yet discover in tuberculin some one or more substances of therapeutic value.

OBITUARY.

Disease has been rife as ever in our midst, and the medical death roll is a heavy one. Not many noted names perhaps, if we except Professor John Marshall, Sir Prescott Hewett, Wharton Jones and Sir Risdon Bennett, but many a young and earnest worker as yet only a few steps upon the ladder of fame has been taken away from us. Not a few of these were victims to that pestilent scourge, influenza, which visited us again last May and is still hovering in our midst threatening once more to become general in this country.

TYPHOID.

Typhoid, too, seems to have been more than usually prevalent, especially in the later months of the year, and the fact that one of our most popular Princes has been down with it has undoubtedly directed the attention of the public to

this insidious disease. Rightly or wrongly a contaminated water supply has generally been credited with the origin of most of our recent outbreaks, and this has led in many of our towns to a healthy spirit of inquiry as to the fitness of private water companies to enjoy the monopoly they at present so frequently possess.

MEDICAL REFORM.

All real friends of medical reform will welcome the important step which has been taken by the General Medical Council in this country in making a five years' curriculum compulsory. It is a useful stipulation that the last year shall be entirely devoted to clinical work.

DEATHS FROM CHLOROFORM.

A more than usually high mortality from the administration of chloroform as an anesthetic, has caused many of our hospital authorities to "consider their ways" in the matter of anæsthetics. Edinbro', it is true, still sticks to her first love, but elsewhere a growing disposition to substitute ether for chloroform is apparent, and this notwithstanding the favorable nature (to advocates of chloroform) of the report of the Hyderabad Commission.

BRITISH MEDICAL ASSOCIATION.

The British Medical Association continue to do good work and to increase the number of its members. The annual meeting held at Bournemouth was a distinct success and will perhaps be especially remembered for the sumptuous character of the social entertainments provided by the local members of the profession. The program of the Nottingham meeting to be held next July is already issued and gives promise of many good things.

INTERNATIONAL CONGRESS OF HYGIENE.

The annual meeting of the British Medical Association, was followed in August by an even more important assemblage of scientists at the International Congress of Hygiene and Demography, which was held in London. Here also much good work was done, and there was also much feasting.

Looking back upon the year 1891, we may say that it has been a fairly prosperous one. Some good and much needed reforms have been brought about in medical affairs, but, as will always be the case, there is still much to be done. That the year 1892 may be a prosperous one to the profession in America is the sincere wish of YOUR LONDON CORRESPONDENT.

LONDON, December 31, 1891.

EDITORIAL ARTICLES.

THE ORIGIN OF SEX.

THERE is something perplexing to the outsider in the way in which certain problems in biology defy attempted explanation at the hands of science. The function of the liver cells can be studied and described with a degree of exactness that amounts to absolutism, while processes which would appear equally within range of scientific observation have a tantalizing way of eluding

detection, though they be submitted to the most vigilant scrutiny. The origin of sex, for instance, would not appear any more mysterious, or any less accessible to scientific discernment, than the function of the cells of the anterior cornu; yet one is revealed while the other remains hidden, and this, notwithstanding the fact that the former is a problem of surpassing interest, the solution of which has an intensely practical bearing for the whole of mankind.

A theory of sex recently promulgated by that accomplished biologist, Dr. Andrew Wilson, of Edinburgh, is deserving some attention, in that it tends to confirm a view that has been acquiring prominence in the minds of contemporary investigators. Dr. Wilson believes the influence determining sex-differentiation to be primarily that of nutrition. Mr. Herbert Spencer long ago pointed out how nutrition affected biological processes, and was ultimately responsible for variations in genesis development and multiplication; and in their recent work on the "Evolution of Sex," Messrs. Geddes and Thompson have held that a catabolic habit of body (or conditions in which a tendency exists to the predominance of waste over repair) favors the production of males, whilst an opposite habit of anabolism (a tendency to constructive over destructive processes) tends to the production of females. This view is supported by experimental evidence, and here nutrition is obviously the key-note to the different phases of sexual development.

suggest that sex

Assuming as well-proved the doctrine that the embryological history of an organism indicates its ontogeny, it is found that until the sixth week of uterine life, the organism is essentially neuter in gender, which would has been specialized from some common hermaphroditic type. fœtus practically hangs in equilibrium for a definite period, and of some bias it has received, it inclines toward one or other sex. this bias?

The sex of each then as a result What gives

Fertilization

Is the bias a nutritive one? Dr. Wilson contends that it is. alone determines the beginning of embryological development, and concisely stated, Dr. Wilson holds "that when an ovum is impregnated before the occurrence of the menstrual period it will develop a male embryo, while conversely if the ovum be impregnated after the menstrual period it will result in female conception." When the ovum is newly extruded from the ovary it is in its most robust and perfect condition, and fertilization at this date gives it a bias in favor of the stronger racial progenitor, imparting to it an anabolic tendency, while contrary-wise should fertilization be post-menstrual, occurring after the ovum has lain sometime in the Fallopian tube, the tendency given is catabolic and the conception will be a female.

While this explanation is on lines convergent with those suggested by Messrs. Geddes and Thompson, a different result is reached owing to reverse conditions prevailing in the human kingdom to those in the animal kingdom in general. In the animal kingdom as a rule, the female is the strongest in a structural and functional sense, and is therefore endowed with a predominant nutritional factor. The fertilization of the ovum when newly emerged from the ovisac, therefore yeilds a female conception.

The objections which could be urged to this theory are of course very numerous, one of the chief being that the prognostications made under its teaching assume for their verification the coincidence of menstruation and