need to imagine, not the detachment of successive emboli, but a shower of them. There is no demonstration that fibrinous exudates do so break up, but all our experience is that the tendency is rather to aggregation and hardening. If Kirke's theory were true we should expect chorea as a concomitant of every case of aortic aneurism, for the fibrinous material ready to be pulverized would be great. The embolic theory is further disproved by the post-mortems upon cases of chorea of rheumatic association in which no lesion of the endocardium existed. Clearly rheumatic chorea is not always caused by fibrinous embolisome other cause there must be.

A poison circulating in the blood and reaching every arteriole undoubtedly exists in rheumatism. This poison, we know, sets up rapid hyperæmias in the joints or serous cavities. It causes serous infiltration. It causes capillary hæmorrhages as shown in the frequent epistaxis of rheumatism. It is capable of setting up these conditions of the blood-vessels elsewhere, and it seems reasonable to believe that it is the cause which sets up these conditions in the nervous centers; in short, instead of saying that rheumatism is a cause of chorea, I believe we should say that the same thing causes either rheumatism or chorea or both. Upon this point Dickinson says: "We see in chorea a widely distributed hyperæmia of the nervous centers, not due to any mechanical mischance, but produced mainly by causes of two kinds, one a morbid, probably a humoral, influence which may affect the nervous centers as it affects other organs and tissues, the other irritation in some mode, usually mental, but sometimes what is called reflex."

It may be objected that inasmuch as the joint symptoms in rheumatism often go as rapidly as they came, leaving hardly a trace behind, we should expect the chorea to do likewise. This does not follow; for the reason that such highly organized elements as those of the nervous structures do not as readily recover their nutritive activity as those of a lower grade. All forms of nervous disease bear witness to the fact that nerve cells whose nutrition has been in any way impaired only recover slowly. Hence, even a quick and transient change of nutritive activity brought about by the rheumatic poison might, and probably does, leave the cells unable to resume their normal function for a long time. The hyperæmia, the serous infiltration may pass off in a few days, the nervous protoplasm takes weeks to recover.

Herein, I take it, lies the explanation of the occurrence of chorea from fright or long continued reflex irritation. An intense mental emotion need not cause either hyperæmia or anæmia; it need not derange the circulation at all, and yet can conceivably cause such a complete exhaustion of the nerve cell that it takes a long period to recover its power of nourishing itself normally. The same is true of reflex irritants.

We are prone to attribute too much to states of the circulation. The bloodvessels may bring to the active cells of any organ perfectly normal blood in perfectly normal amounts, but the individual activity of the cell after all dictates whether the blood shall be used or not. "You can take a horse to water, but you cannot make him drink." You can vary the blood supply, but you cannot make the cell drink. So, after the transient hyperæmia of the rheumatic poison, or after the cell is exhausted either by a sudden great disturbance, such as a fright, or after a constant small disturbance, such as a

reflex irritant, we must wait until the nerve cells slowly regain themselves. I have spoken of the hyperæmia of the rheumatic poison. It would seem that in many cases the rheumatic poison exerts its influence upon the protoplasm of the cells directly without any hyperemia at all. This is probably what occurs in those cases of recurring chorea in which, after the first time, no signs of rheumatic affection elsewhere can be found. Upon cells once injured by the rheumatic poison it seems to need the action of only minute quantities of the rheumatic poison to reproduce the old defect.

If these views of the relation of chorea and rheumatism be correct; if the same poison circulating in the blood, acting either directly upon the protoplasm of the nervous cells or indirectly by causing a hyperæmia of the cerebral and spinal blood-vessels, cause chorea, and acting throughout the body cause rheumatism, we should keep two things in mind:

First, that the chorea continuing after the rheumatic symptoms have ceased does not call for a continuance of the anti-rheumatic remedies, but rather for such measures as will tend to restore the nutrition of the nerve cells.

Second, that a person who has once had chorea of rheumatic origin should keep up such regulation of diet, clothing, habits of life, and atmospheric conditions, as will best prevent the slightest rheumatic poisoning. This should be done for two or three years, even though no rheumatic symptoms appear. Our commercial relations with our patients compel us to cease our supervision of them as soon as the acute disorder is over. Were we to stand to them in the more philosophical position of permanent medical police we could regulate matters so that recurring attacks of chorea would largely cease.

DR. EMERSON: That there is a significant relation between the two diseases is apparent, and that they frequently alternate is everybody's experience, but to positively assert that they stand in relation of cause and effect is difficult. I call to mind a case of chorea occuring in a child before the age of puberty. Three times she recovered, and three times relapsed, until finally after the third relapse she developed a high fever, followed in a few days by an acute articular rheumatism and endocarditis, which left a permanent mitral murmur. This case suggests, but does not prove, the connection. Arsenic is good in chorea, but of no value in rheumatism. The salicylates are good in rheumatism, but of no value in chorea. Chorea has a distinct tendency to disappear of its own accord. DR. J. B. NEWMAN: I could never see that the two diseases were related. In rheumatism we have lactic acid as a permanent lesion. In chorea a nervous element is the permanent lesion. Rheumatism affects the negroes, chorea almost never. Chorea affects intelligent, nervous people, and is a central nervous lesion affecting the brain rather than the cord, as is shown by the suspension of the disease during sleep. In rheumatism we have a urine of high specific gravity. I would say, therefore, that the diseases are distinct.

DR. C. W. HITCHCOCK: Some statistics show that rheumatism stands in the relation of the cause of chorea; other statistics show that it does not. Weir Mitchel's statistics show that the rheumatism is a predisposing cause of chorea only in as much as it lowers the general vitality. Recent statistics show that there is a correspondence between the existence of chorea and storm centers, showing that there is something in the weather which affects similarly both diseases. The existence of storm centers affects rheumatism and chorea much more than ordinary diseases.

DR. DONALD: There is a close connection between the two diseases. If it be not atmospheric it must be from some poison in the blood. The hyperinosis being the indication of that poison, the exact nature of which is undetermined.

PREVAILING DISEASES AND REPORT OF CASES.

DR. GEORGE W. STONER: A man was sent to the Marine hospital on account of a foot which had been crushed and amputated. His bladder was found to be full, the catheter was passed and the urine removed, but when we came to withdraw the catheter only half of it came away. By persistent manipulations half of what remained was removed. It was found impossible to reach or remove the remaining portion. It was determined to leave it until the man recovered from his injuries and then perform lithotomy if necessary. Much to my joy, however, after twelve hours the man passed the remaining piece of catheter per urethram. DR. F. W. ROBBINS reports a case of strangulated hernia in a child. Hernias in children are not unusual, especially the congenital variety, but strangulated acquired hernia are rare, and for this reason my notes on this case may be of interest. F. C., aged eleven months. Several times during the summer I had prescribed for the child on account of diarrhoea, but had not seen him for some time, when on the evening of September 3, 1892, his mother brought him to my office. There was present a lump in left inguinal region noticed for the first time the previous evening by his mother, at which time he had a movement of the bowels. There had been no vomiting or severe pain, although the child was quite restless. There was no impulse on coughing or crying, nor could the testis be discovered hidden behind the tumor, which had a slight sense of fluctuation. These symptoms hardly produced the symptomatic picture of strangulated hernia. Under chloroform taxis produced no effect on the tumor, and as this was a very busy morning and the case not urgent, I ordered poultices to be applied until afternoon when, as there had been no change in the condition, I carefully cut down upon the tumor, where I found a knuckle of intestine over half an inch long, highly congested, in a sac filled with serous fluid. Upon nicking the constricting band at the internal ring the gut was easily replaced, the sac cut off and deep and superficial stitches inserted. The patient is well, with the exception of a congenital phimosis which I shall attend to in a few days. Possibly the result is much better than it would have been had we waited for more serious symptoms. In such cases it is not wise to delay, but when gentle taxis under chloroform does not avail, have recourse to the knife. Dr. Sherrill kindly assisted me in the operation.

DON M. CAMPBELL, Secretary.

EDITORIAL ARTICLES.

SYMPHYSIOTOMY.

ANTISEPTIC methods have lessened the mortality of the various Cæsarean operations to such a degree as to make them no longer the most dreaded alternatives to which the parturient woman can submit. Nevertheless, it is felt that any expedient for rendering these formidable operations less frequent cannot but

be a boon to suffering humanity. The mortality of Cæsarean operations is still sufficiently high to make them an ulterior choice when other effective or practical methods of dealing with pelvic deformities present themselves.

During the last six years the operation of symphysiotomy, or should we say pubiotomy, has been slowly growing in favor. The operation which consists in severing the ligamentous union at the symphysis pubis is an old one and was first suggested by Pineau in 1598. It is, therefore, three hundred years old. During these three centuries which have elapsed since its inception eighty-five operations have been made with a mortality of thirty-three per cent. From January, 1886, to the present date, that is to say during the era of antiseptic surgery, there have been fifty-two recorded cases of this operation, with only a single death, and this death apparently due to avoidable septic infection. That the operation has grown in favor is shown in the fact that twenty-one operations have been made this year in Italy, France, and Germany. Two operations have been made in America, the first case being that of Dr. Charles Jewett, of Brooklyn, recorded in the November number of the Brooklyn Medical Journal.

The usual method of performing the operation consists in first severing the attachments of the recti muscles to a sufficient extent to admit the introduction of the finger below the symphysis. A blunt-pointed bistoury is then introduced along the finger and the ligaments cut upward and outward. The insertion of a probe secures protection to the urethra, by allowing it to be pushed slightly to one side. The spreading of the pelvic bones is usually immediate, and permits the speedy extrusion of the presenting head. The symphysis unites after the operation without complication.

The operation is doubtless destined to become a recognized surgical proceeding. That it will in some measure replace the barbarious practice of craniotomy is to be ardently hoped, and the fact that so distinguished a champion of Cæsarean operations as Leopold has recently advocated its employment, speaks well for its use in cases which would otherwise be relieved by more strenuous

measures.

HOMEOPATHY IN THE STATE UNIVERSITY.

THE homœopathic department of the state university has been recently occupying public attention, and the numerous rumors in circulation regarding its status and prospects have given rise to several interviews in the daily press. There is good reason for believing that whatever may have been the nature of the newly-projected scheme, it has by this time succumbed to arrest of development. No proposal, contemplating a new professor of anatomy, or a division of the practical chairs of the regular faculty with members of the homoeopathic faculty, has been submitted to the board of regents. Several of the board have, however, been individually approached, and some have even acquiesced in the wisdom of an arrangement which would curtail the present expense of maintaining two schools. The proposed arrangement whereby most of the chairs of the regular department were to be split in twain and divided with the homœopathic faculty, did not, however, seem to meet with much approval at the recent meeting of the homoeopathic faculty. This, however, might be due to the absence of its chief promotor from their counsels. The regular faculty have not committed

themselves, further, it is said, than to place on file the communication suggesting these changes, and the profession of the state can doubtless rely upon their wisdom to avoid effecting any undignified compromise with the votaries of sectarian medicine.

EDITORIAL BREVITIES.

THE PAN-AMERICAN MEDICAL CONGRESS.

THE preliminary announcement of the Pan-American medical congress has been issued. It is a handsomely printed document, and indicates an amount of industry on the organizing officers which is very creditable. The expenses of organization are very high and have to be met out of registration fees. It is therefore important that those who intend to join the congress should send their fees as soon as possible to the treasurer, Dr. A. M. Owen, Evansville, Indiana.

MR. TAIT AS AN AGITATOR.

MR. LAWSON TAIT is occupying a very discreditable position on the vivisection question. He is fraternizing with bigoted theologians, whose insults to the profession to which Mr. Tait belongs are unpardonable. At a recent meeting of the antivivisection society Mr. Tait was introduced as "the hero of the meeting," "the Athanasius contra mundum." Mr. Tait can do the damnation act as well as anyone since the days of Athanasius, but he is hardly qualified to "offer to the British public an apology on behalf of his profession." It is superfluous for Mr. Tait to apologize for the achievements of Lauder Brunton, Hughlings Jackson, and Victor Horsley. Their work will answer for itself when much that Mr. Tait has done will have been forgotten.

HYPOCRITICAL ANTIVIVISECTIONISTS.

Or apt illustrations of the hypocrisy which so frequently prevails among antivivisectionists, Mr. Victor Horsley gave two striking specimens in his address before the church congress at Folkestone. One affected the reputation of Mr. Lawson Tait, who was announced to speak in the interests of antivivisectionists, but who permitted a resolution endorsing vivisection to pass through the British medical association without protest. The other concerned the Duke of Newcastle, a vice-president of an antivivisection society. The duke's brother was bitten by a dog, and the duke desiring to know if it had rabies took the dog, after killing it, to Professor Horsley. He was informed that inoculation experiments alone could determine the question of rabies. To these experiments the distinguished antivivisectionist assented, and frequent enquiries were made on behalf of the duke to ascertain the result. Probably the sentimentalism of most antivivisectionists would not survive the bite of a rabid dog.

PETTENKOFER AND THE CHOLERA VIBRIO.

PROFESSOR VON PETTENKOFER does not believe the comma bacillus to be the sole cause of cholera. The constant occurrence of the microbe in the excreta of cholera patients indicates that it holds some etiological relation; but it is open to doubt whether it be alone the cause of disease. To test the point the Professor made some personal experiments. Several of his pupils offered themselves for