chloroform in these operations as usually the operation can be done without the danger of the anesthetic.

DR. J. E. LOGAN, of Kansas City, thought that 50 per cent is too low for the proportion of adenoids causing some trouble of the middle ear; 65 per cent is more nearly correct.

P. L. KABLER, of Hannibal, expressed himself as opposed to chloroform except in the very worst cases.

DR. FRANK R. FRY, St. Louis, read a paper, "The Signs of Degeneracy in Various Diseases of the Nervous System." Degeneracy, he said, means a loss or impairment of the natural or proper qualities, or of qualities peculiar to a race or kind or type. The theory is that marked signs of this degeneracy are manifested in stigmata. By means of these it is claimed that it can be told whether a man is of stable or unstable character. a normal person or a degenerate. About 5 per cent of all individuals have some stigma. The object of the paper is to indicate the practical ap plication of facts already well known: but this must be rather unsatisfactory as we are not yet able to go into the refinements of the subject. All stigmata may be classed under one of three heads

1. Somatic or anatomical.
2. Physiological.
3. Mental.

Each embraces many important items. 1. The anatomical stigmata may be divided into (a.) General, as congenital shortness of height, the left side longer than the right, general feebleness of the constitution, etc. (b.) Cranial, as asymetry of the skull (especially in the frontal region), short parietal arch (notably in epilepsy), a short frontal arch and peculiar conformation of the head, viz; Trigonal scaphocephalic and plogiocephalic. (c.) Muscular, as unequal development of the two sides of the face, and depression over the glabella. (d.) Deviations from symmetry, as long, irregular and prominent ears, bad teeth, deviation of the nose, deformed genitals, etc.

2. The physiological stigmata are not quite so well marked, but are sometimes very distinct. The chief

ones are (a.) Deficient vital or organic functions (weak heart and low ar terial tension); (b.) Lowered vaso-motor vitality, as shown by persistent coldness of the extremities; (c.) Chronic constipation without decided organic cause; (d.) Sexual perversions.

3. The psychical first attracted attention. The principal ones already known are (a.) Feeble or erratic mental activity, with unstable will. (b.) Lack of emotional control. ficient moral sense.

(c.) De

Many of these stigmata are of little significance in themselves. But they are of importance, particularly as having a bad prognostic value in cases where the neuroses or psychoses develop. In neurasthenia they are of more import many times than are the "reflex causes" to which so much attention has been paid of late-astigmatism asthenopia, tender ovaries. lacerated cervix, etc. The lesson is that when any of the stigmata are present we should not confine our treatment to the single removal of the cause, but vigorously combat the degenerative tendency of the nervous system by proper internal medication. And they should also greatly influence our prognosis in such cases--they are destined to be always neurasthenic in spite of any medication or line of treatment. We should operate to remove diseased conditions, surely, and correct any ocular or other irritation; but we should never promise a cure therefrom when any of the stigmata are pronounced. The same is true of hysteria, epilepsy, insanity, etc., apparently caused by some local irritation. Mental stigmata are just now prominent on account of their recent introduction into murder trials. Physicians should be careful not to lay too much stress upon these signs in establishing criminality, yet give them all due credit in determining the existence of insanity.

DR. M. P. SEXTON of Kansas City, expressed himself as an optimist as regards the degeneracy of the Nation; while individual degenerates are be coming more numerous the world as a whole is moving in the right direction. But on account of their prognostic and legal importance we should make a more careful study of these degen

erates; and of the physical condition of all of our patients. We have not yet a sufficiently definite knowledge of the subject to be of much practical value, but it is necessary we should give it much more thought and attention than in the past.

DR. W. F. MITCHELL of Lancaster, discussed the subject of "Rational Medicine." He claimed that scientific medicine has advanced equally with chemistry, physics and the higher mathematics. So great has been the progress that we no longer employ any agent empirically, but subject it to the experimental ordeal based upon physiological grounds; if it cannot stand the test it is rejected. As a consequence we are not sticking closely to Galenical preparations, but adopting new remedies and combinatins regardless of their origin. He favored proprietary articles. He inveighed against professors in medical colleges, claiming that most teach not for profit nor yet for the advancement of science, but for personal gratification and advancement; he believed the time has come when we should put a stop to this kind of work by ceasing to seek consultation, etc., with these self-elected "leaders" of the profession. Many of them give testimonials for patent medicines-just as bad as the doctors of divinity. He made an attack on newspapers for helping quack doctors and medical college professors by free advertising, etc., and ended with a plea for rationalism in practice. The doctor who practices rational medicine, he said, is the one who saves the innocent and delivers the criminal over to justice; who stands by the injured in determining the capacity of individuals to dispose of property; who prevents hanging of the truly insane and removes lunatics from the jail to the hospital; who educates the blind, deaf and dumb; who instructs the people as to food, and hygiene; who prevents epidemics; who condemns the use of alcoholic liquors as beverages; who treats dipsomania, cures women of their ailments, employs systematic massage, Swedish movement, avails himself of the advantages of hydrotherapy, electrotherapy and prescribes such remedies as his judgment dictates.

295

DR. T. E. MURRELL, of St. Louis, considered it an outrage the way patent medicines are endorsed, advertised and sold. There are many doctors in the country who actually dispense patent medicines to their patrons, and many in the city who do just as bad, prescribing "Castoria," "Pond's Extract," and the like. It is the duty of the physician to educate the people against the use of such things and to induce the legislature to pass laws requiring publication of formulae upon every package of patent medicine. So far as the newspapers are concerned, they are beyond hope. For example, a traveling, advertising quack once came to Hot Springs, claiming to cure all eye diseases; he found a case of cataract, knew he could not cure it and so only gave some ointment, subsequently writing to Dr. Murrell, asking him to operate on the case, divide the fee and not let it be known that the traveling charletan did not cure the case. When this matter was offered the newspapers of Hot Springs they refused to allow any notice of it to appear in their columns. This is a sample of newspaper "honesty" toward the medical profession.

DR. KABLER said that physicians are not above censure themselves. They recommend proprietary and patent medicines more frequently than do any other class of men.

DR. J. F. BINNIE, of Kansas City, reviewed the "Pathology of Tubercular Arthritis." He regarded the fact as now well established that strumous joint disease owes it origin primarily to the bacillus tuberculosis, brought into activity by a slight trauma, a light inflammation, or by an embolism which usually is located in the epiphyseal ends of bones, primary synovial tuberculosis being rare. So if osteal tuberculosis can be recognized and located before the proper structures of the joint become implicated much trouble can be prevented by early operation. In old people the tendency of tubercle in joints is always to break down into pus at an early day-hence the prognosis is not so good as in young subjects. In adults the tubercle sometimes affects the synovial membrane first; these

are the cases which yield so readily to iodoform injections, cure being effected by absorption of the diseased tissue and replacement by healthy granulation tissue. In osteal disease the same result may be obtained and even small sequestra may be absorbed and replaced by healthy bone tissue provided there be no mixed infectionthat is, infection with the staphyllococci of pus. The liquid, caseous matter which is sometimes met in aspiration of joints or in operation, should not be regarded as true pus unless the microscope reveals the peculiar organisms of pus; the lesson is not to relax aseptic precautions simply because a creamy, purulent-like liquid is found to be present.

DR. T. F. PREWITT, of St. Louis, discussed the "Treatment of Tubercular Arthritis." He favored immobilization by fixation, especially in young subjects; also injection of iodoform emulsion or a solution of bi-chloride of mercury into the peri-articular tissues. Too little attention has of late been paid to hygiene, fresh air and internal medication. Codliver oil is a time-tried remedy usually given in too large doses. Guaiacol and creasote have given excellent results-the latter particularly. Hypophosphites, in the form of the compound syrup, acts well where oil is not well borne. But in older patients fixation of the joint and intra-articular injections frequently do not check the disease. When this is the case operation must be resorted to. The operation now most in vogue is curettage, which is always advisable where the bone only is diseased, the synovial membrane not yet being attacked. Later erasion, or a typical resection is indicated opening the joint freely under irrigation, cutting away all diseased areas, packing the cavities with dry iodoform and draining with gauze. Excision or resection, and amputation must be left as the last resort, particularly in child

ren.

DR. A. L. FULTON, of Kansas City, could not believe that a slight trauma is the cause of the local tuberculosisit is preposterous. Every case of joint tuberculosis originates outside the joint, the tuberculous focus being found nearly always in the cancellous

296

tisue where the lymphatics are numerous, the tissue exceedingly vulnerable and histologically so constructed as to be not easily repaired; this is what really constitutes the so-called "locus minoris resistentiae." The outdoor treatment is decidedly the best, but immobilization is not of so much value as usually taught; in fact joint fixation is often accountable for many bad results which passive motion might have prevented. Iodoform injection will cure fully 80 per cent of cases seen early-and it is especially good just at the beginning of suppuration. The patient should be allowed to use the iodoformized joint as much as he likes. The bad results that have been reported from the use of iodoform emulsion come from the fact that too little iodoform was used at the site of disease, most surgeons being afraid of iodoform poisoning; there is really little danger except in hydrops articuli, where the emulsion is widely desseminated. In one case in his practice 112 grains did cause serious symptoms when thrown into two joints simultaneously. But the injections cured the disease promptly.

DR. A. J. STEELE, of St. Louis, declared he could say amen to all that had been said excepting the injection of iodoform. If the disease, as is claimed, is extra-articular, the chances are greatly against the iodoform reaching the affected tissue. There can be no doubt as to its efficacy in curing synovial tuberculosis when the bone is not very seriously diseased. But in primary osteal tuberculosis, especially in young persons, early immobilization and good internal treatment and food will cure a large proportion of cases. Air and sun seem really the best treatment, even in little children with hip diseases it is best to put on a stretcher-splint and send the little ones out; later when the muscles become relaxed a portable splint can be applied. Passive motion should be instituted as soon as the inflammatory symptoms subside. No operation is required in a large majority of cases.

DR. JACOB GEIGER, of St. Joseph, agreed as to the majority of these cases being extra-articular in the beginning, though a few are unquestion

ably primarily synovial in origin. But slight injuries are certainly the exciting cause as has been clearly demonstrated many times; a lowered vitality and other signs of a "strumous diathesis" are present in these cases. Extension and fixation are essential, generally, to prevent deformity. Tar is a good remedy for tuberculosis, but creasote is a delusion. The chief indication is to improve the general condition. Gold and manganese seem to be the best agents for this purpose. By reason of the excellent results now obtainable by iodoform and curettage excision and amputation are not now necessary except in rare cases where osteomyelitis is very marked.

DR. BINNIE believed immobilization good in early tuberculosis-no one can doubt that it is Nature's method of cure. Zinc chloride injections have given almost as good results as iodoform, but the latter possesses the advantage in that if it does not do any good as a curative measure it prepares the joint excellently well for operation; hence the emulsion may well thrown around the joint at the same time it is injected into the joint. Guaiacol in doses of three to five drops three times daily certainly does do much good and should be now regarded as a part of the routine treatment.

be

DR. PREWITT thought there has been too much confusion as to the pathology. Whether it manifest itself as a fungous arthritis, a hydropsarticuli, a synovitis, or otherwise, it should be considered tuberculosis regardless of the manifestations-they are all one and the same thing as to character. The chief question is: How to deal with a chronic joint inflammation? The ideal treatment is to remove the diseased foci where they can be located; otherwise iodoform injections must be employed. Where the disease is far advanced curettage and packing seem to be almost universally accepted as the proper treatment, severe operations being done only as a dernier ressort, something to be thought of only after all other lines have failed.

DR. L. J. MATHEWS, of Carthage, read a paper upon the subject of "Immunity from Disease-Natural and

Acquired." He said there are certain forces in the human economy which we must recognize. Vital or life force, and the natural resistance of the body to disease are factors that cannot be ignored-they are too important in the question of treatment of disease. We say a man has immunity when he is not affected by agents which usually cause disease; as the ambulance driver in St. Louis, who spent twenty-five years in transporting all sorts of disease and then died from a chronic disease; this was natural immunity; had he contracted some of these diseases and then been unable to have second attack, or had he had protective inoculation (as vaccination) this would have been acquired immunity. There are numerous instances of natural, even of racial immunity; thus the negro is not susceptible to yellow fever and only slightly so to malaria. Then there is individual immunity. The questions naturally arise: What is this? What keeps certain people from taking disease? If we can discover the causes cannot we supplement them? We are approaching the solution of these grave problems. We have found that many-indeed most diseases depend upon specific germs. Infection by these germs is due to the non-resistance of each individual to that particular form of disease, or its Were it not for this natural immunity whole communities would be swept away at every epidemic. The question of greatest import now is not how to destroy the germs of disease or prevent their multiplication but how to render the individual immune. We know there must be a lowering of vitality somewhere. as a germ cannot affect a perfectly healthy tissue-cell action is too strong; phagocytosis is the protector. The inference is therefore that natural immunity is nothing but absolutely perfect health. But it is claimed that the typically healthy man rarely exists. So complete immunity to all disease is rarely met. Yet the lesson is that by improving the general condition, by attention to the laws of health, by exercising common sense in contracting matrimonial alliances, etc., we can build up this natural immunity to a marked degree. Previous attacks

germ.

also immunize in some cases, notably variola, whooping cough, measles and scarlet fever; acting upon the principle Jenner did his work in variola; the antitoxines are the result of the same theory carried out thus far with very encouraging results in some cases; but the diphtheria antitoxin does not render the patient immune to future attacks, as one patient cured of the disease subsequently died of a second attack; and the sequelae of diphtheria are said to follow cases treated by this remedy just as if the disease had been allowed to proceed. The latest application of immunity to treatment is the cure of phthisis by injections of the blood serum of the horse, an animal naturally immune to tuberculosis. Tetanus also seems to promise much But all that is claimed in regard to these must not be accepted until better established. The cure of none has as yet been unquestionably proven. Modern investigators are much too eager to publish their "discoveries;" they should follow the example of Jenner who waited twenty years before giving the world the results of his investigations.

DR. C. LESTER HALL, of Kansas City, was inclined to think the future of medicine and of practical therapeutics lies along these lines-there is much more to hope for than from the empirical methods of the past. The use of such agents as the blood serum, nuclein, antitoxin, etc., together with preventive medicine and sanitation will constitute the management of disease in the near future. We are at present in a sea of uncertainty but something is being done for good.

DR. J. P. THATCHER, of Pisgah, recited the history of "Three Cases of Pleuritic Effusion," with remarks. The first case was a Prussian soldier who had a simple pleurisy with effusion. He was given a quantity of whisky, and aspirated while under its influence, two or three quarts of thin, watery pus being withdrawn. He was discharged in two months completely cured. Under resection he would have been confined to his bed much longer and would have had much chest deformity therefrom, whereas he now is in such perfect shape as to be again in the army.

298

The second case was a girl of 15 years, illy developed, who had a suppurative pleuritis following pneumonia. She was first aspirated; then as the pus re-accumulated a small drainage tube was inserted and she gradually recovered without resection and without much chest deformity.

The third case was a girl of 41-2 years who had pneumonia and then pleuritis. She was aspirated and fifty ounces of pus removed; later a drainage tube was inserted and irrigation with dioxide of hydrogen practiced. She was discharged cured in ten weeks, the drainage tube being removed in the seventh week. All cases had syrup of hydriodic acid with strong tonics internally.

From these cases the conclusions are drawn that (a.) Resection is never justifiable in simple effusion. (b.) Aspiration is all that is needed for serum and for fluid blood. (c.) Simple drainage is all that is needed in many cases of empyemia. (d.) Resection should be reserved for patients beyond middle life.

DR. C. F. WAINWRIGHT, of Kansas City, contended that the first case was one of simple pleuritis with effusion, that belonged to a class in which no man would do anything more than aspirate and give medicine internally; but extreme care must be exercised in such cases not to infect the patient by aspiration, transforming a simple effusion into a purulent accumulation by the introduction of germs from the skin or through the lung by carrying the needle through into lung tissue. The other two cases were children, and it is a well known fact that children recover from empyema by aspiration only, without chest deformity, if treated early enough. But if the essayist were to try to carry out the same line of treatment with adult patients only disaster would attend his work. Here free drainage must be provided for by a large opening in the chest wall and if the lung does not expand when the pus is evacuated portions of several ribs should be excised so as to allow collapse of the chest walls since cure cannot be accomplised except by allowing the two walls of the pleura to come in contact. It may be said, too, that