seriously the appearance of "metastatic" impetigines, in the sense used by Hebra. In all the cases of impetigines found on the cadavers resulting from lethal infectious disease, as mentioned by me heretofore, I found the cocci just under the horny layer of the skin and never as vascular emboli. Why, recently, I stained, with a view of bringing out the cocci, a specimen taken from a case of pyæmia when impetigo was present, and which I had kept with a certain degree of reverence for many years, and found the cocci, not as I had expected, in the vessels, but in the remains of a lanugo bulb! Even Hebra, senior, would have found this external method of infection, if he had known it, more congenial than his "metastasis" hypothesis which he evidently assumed as a sort of a make-shift. I would also like to call attention to the significant fact that the horny layer covering many impetigines harbors such multitudes of staphylococci (and generally pure ones at that, staphylococci free from the many otherwise frequent bacteria), that it becomes easily understandable how, on the one hand, very slight influences, such as friction, warm poultices, a watertight covering, etc., can even after an apparent cure, bring on returns and relapses of impetigo; and on the other hand that impetigoes may extend over such unconscionable lengths of time, particularly impetigoes of the face. I consider that a sure simultaneous sterilization of the epidermis down to the basal horny layer by any external, non-corrosive application, is an impossibility. A radical treatment of the older cases succeeds best when prosecuted under methods analogous to the intermittent sterilization of culture media.

Finally I would state, as another result of my experiments, that in spontaneously originated impetigines, in no stadium have I found staphylococci within the leucocytes. The cocci, usually in cluster-shaped colonies were always found surrounded by leucocytes, dead in vivo and which took a stain poorly, but the penetration of the same, described by so many observers as witnessed in other purulent diseases, was never witnessed. At least Dr. Walker, of my laboratory, who always verified the results of my sectional preparations by means of cover-glass preparations of fresh impetigenous matter, never succeeded in finding any such condition. If it ever occurs in impetigines it is exceptional.

With these short remarks I will bring my re-presentation of

the histology of impetigines to a close. This much, doubtless, will be conceded, that we have a well-grounded right to speak of true superficial or epidermal abscesses, and further, in the complete histological uniformity of all efflorescences which correspond to the clinical phenomena above set forth, the duty is incumbent upon us to maintain and insist upon the acceptation of this clinico-histological syndroma as the type of purulent diseases of the epidermis.

If this is admitted, it follows that a large number of pustular diseases, to which we in recent times have ascribed the same genesis, but which yield entirely different results, histologically, must at once be removed altogether from the category of impetigines. Until proof of an etiological connection is established we would suggest that the adjective "pustular," instead of impetigenous," be applied to them. Thus, for example, I have recently been endeavoring to narrow down the mixed infections with pus cocci occurring in tuberculosis as well as in syphilides of the skin. I do not go so far as to demand that the histological picture of the impetigines as portrayed by me shall be exactly reproduced in mixed infection of the skin. On the contrary we must just there expect to find modified histological phenomena; but the simple demonstration of the presence of pus cocci by cultivation, which was formerly sufficient evidence for me to accept a mixed infection (in the scrophulodermata, for instance) will no longer suffice; since, from the anatomy of impetigo and furuncle, the prime fact appears that the pus cocci always surround themselves in the epidermis, as well as in the cutis, with a wall of leucocytes which they never overstep. Viable staphylococci, without the mantle of pus, will therefore be found only within the horny layer or the hair sheath, where they can multiply up to a certain degree, only, without causing the formation of pus. In the papillary layer and cutis, on the contrary, one can, in the absence of miliary abscess, with certainty exclude the presence of the pus-bearing staphylococci.

By their seat solely under the horny layer, by their pus color; by the fact of their being single chambered; by the absence of depression; by their rapid development and simple, slow desiccation, without oozing or coagulating secretion; by the absence of inflamed area and base, serous vesicular

origin, subjective sensations and later of scar formation; by the absence of typical size and localization, by all these is impetigo, caused by the white and yellow staphylococcus so excellently characterized that it can never be mistaken, whenever it occurs uncomplicated.

But the question whether there are not pyophorous organisms other than the known staphylococci which might cause the same or similar pus vesicles, is yet to be answered. Indeed, I am of the opinion that certain staphylococci and bacteria too, that cause epidermal abscess are similar to those described.

To prove or disprove the existence of these, and if possible to differentiate them clinically, will be one of our next tasks in the near future, as well as the proof of the differences presented by the phenomena of the pure staphylogenetic impetigo and those of the mixed infection. It will be that the manifest conception of the impetigo of Bockhart must be widened into a conception of a family which embraces all epidermal abscesses in so far, at least, as they are induced by pyophorous micro-organisms. Our impetigo would then demand a more rigorous terminology, and would be called impetigo staphylogenes.

Fine Diagnosis.-Dr. Lauder Brunton in a recent address laid great emphasis on the necessity of care in diagnosis and gave some amusing instances of errors in this important part of a physician's work, due to too hastily formed opinions. In one case he was among a class of students around a man suffering from heart disease, when it was noticed that the pupil of one eye was much more dilated than the other. At once numerous more or less learned suggestions were made to account for the mydriasis. Eventually the man informed them that the eye over which there had been so much animated debate was a glass one. Another instance related to a learned professor who used to boast that he could tell much concerning the medical history of his patients by their teeth. When holding forth on his favorite theory one day he was considerably disconcerted by the patient taking out the complete set of masticators, and saying: "Perhaps the gentleman would like to look at them closer."

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AMERICAN MEDICAL ASSOCIATION.

The Detroit meeting of the Association was, without doubt, one of the best that it ever held. The attendance was quite large and a great deal of work was done both at the general meetings and in the Sections. The latter were thoroughly organized and well attended, the members there seeming to take more than an ordinary show of interest. This meeting amply demonstrated the fact that a little effort on the part of the members is capable of accomplishing great good and of showing a great deal of the best kind of work.

The "new-code" men created quite a sensation, the question being revived as to their acceptance as delegates to the Association. The conclusion reached was to leave them unmolested for this year and, on resolution, a committee of the Association was appointed to confer with the New York Society in order to see if ways and means could not be devised whereby harmony could be secured. For a time, a large sized row appeared imminent, but wise councils prevailed and white-winged Peace complacently flapped her expansive wings over the turbulent members.

The social features of the meeting were numerous and well planned. The receptions, carriage rides, yachting excursions, etc., were judiciously planned and every one found enjoyment to his heart's content. In fact, the Detroit profession did everything in its power to make the occasion one long to be remembered.

The Pan-American was Congress represented by a goodly number of its Board of Trustees who reported good progress. Dr. Wm. Pepper, the President, and Dr. Charles A. L. Reed, the Secretary-General, addressed the general meeting in behalf of the Congress. They made an appeal for funds requesting the members to enroll themselves as members of the Congress and pay the dues in advance, thus ensuring funds sufficient to pay the necessary preliminary expenses. The call we are pleased to state, was responded to generally.

The sections all did good work and elected each one an executive committee of three. These will constitute the managing committee of the Association to whom all matters of a legislative nature will be referred. In this manner much valuable time will be saved and matters expedited. The choice of Milwaukee as the next meeting place was rather a good one, although it did seem that another section of the country should have been chosen. It is located, practically, in the territory of Detroit and it would seem almost as if the Northwest had too many meetings. However, good attendance is already predicted so that we may expect better work than ever. As to the city, it is hospitality itself.

EDITORIAL NOTES.

DEATHS FROM SWALLOWING ARTIFICIAL TEETH SEEM TO BE QUITE NUMEROUS.-The case reported in the daily newspapers last week (Brit. Med. Jour.), of a police constable who met his death from the impaction of a set of artificial teeth in the neighborhood of the larynx should draw general attention to a danger to which many are daily exposed. It will be remembered that in this particular case the constable, summoned by the whistle of a comrade conveying a prisoner, whom there was an attempt to rescue, to the police station, came running up and took hold of the arm of the prisoner, but almost im. mediately fell to the ground. He was at once conveyed to King's College Hospital, but died on the way there. The post-mortem examination revealed a set of false teeth impacted just above the larynx, and this had caused death from suffocation. The report adds that the teeth were of inferior make and no doubt became loosened through the deceased running. Year after year there are recorded cases of death from swallowing artificial teeth and probably many occur