DERMATOLOGY.

ROBERT H. DAVIS, M. D.

Observations on the Use of the X-Ray in the Treatment of Certain Diseases of the Skin. -Wise (Med. Rec., Jan. 20, 1906) gives an elaborate article on the results obtained with the X-ray in the treatment of various dermatoses at the New York Skin and Cancer Hospital. His conclusions are: (1) The X-ray will cure ring-worm and favus of the hairy skin more rapidly and reliably than any other method of treatment; the advantages of the method are that it is painless, harmless when properly used, and thorough. (2) Hypertrichosis should be treated with electrolysis, not with the X-ray. (3) The X-ray gives very satisfactory results in the various forms of cutaneous tuberculosis; in keloid, in keratoses, in infiltrated patches of chronic eczema, lichen planus, pityriasis rubra; in the tubercles, ulcers and tumor masses of mycosis fungoides, in psorospermosis, and in idiopathic, multiple, hemorrhagic sarcoma. (4) X-ray relieves pruritus, burning, tingling, and often pain; it decreases the discharge and foul odors of various dermatoses, often causing them to disappear completely. (5) In selected cases, radiotherapy is the ideal agent in the treatment of epithelioma and rodent ulcer. Of course, in a certain percentage of cases of epitheliomata of the skin, there was no benefit whatever from X-radiation, while not a few became more extensive and intractable, but this was not true of the great majority of cases treated. The recent, superficial, non-extensive growths yield most easily, but it was found best to exercise radically all cases suitable for such action, and in which consent to operation could be obtained. The X-ray can then be used to prevent recurrence in the scar. The cases of lichen planus referred to were of the hypertrophic form. In cases of keratosis palmaris et plantaris, the X-ray was applied to the palm, and sole of one side, and strong salicylic acid plasters to the palm and sole of the other. Radiotherapy showed much the better results; the treatment causing no inconvenience, the effect was more lasting, and the necessity of having the hand covered with plasters and bandages was eliminated. (The editor saw and treated one of these cases, and can fully concur in the advantage of the X-ray therapy.) In the treatment of keloid, it was sometimes necessary to push the exposures up to the point of ulceration. When the ulcer healed, and the scab dropped off, a large portion of the tumor was found to have disappeared. This was for small keloids on the chest and arms. In the large keloids of the face, neck, and chest, the X-ray caused a decided softening and dimin

ution in the size of the tumor masses. The author does not state whether the raying in these cases was pushed to the point of ulceration or not, but presumably not. In the extensive, diffuse, keloidal conditions following burns the results were unsuccessful. In tinea barbae, the so-called non-parasitic sycosis, and the "ingrowing hairs" frequently seen on the neck of young men who use the razor, the results were satisfactory in the extreme. He gives excellent advice with respect to the caution with which the X-ray should always be used. Suitable protective measures should, of course, be taken, and the effect of each treatment carefully noted before repeating it, as the burns resulting are (except apparently in leprosy. See abstract in this issue.-Ed.) peculiar obstinate in healing.

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Leprosy in the Philippines, with an Account of Its Treatment with the X-Ray.-Wilkinson (Jour. A.M.A., Feb. 3, 1906) gives some exceedingly interesting data and conclusions based on the large number of cases he has seen, and the thorough test to which the Xray has been put in treating them. He is inolined to believe that the disease is rarely, if ever, transmitted from parent to offspring, and is with difficulty transferred from one person to another, but there frequently exists a common source of infection to which the members of the same family may be subjected, especially during early childhood. merous children under his care born in the Philippines of leprous parents (seven in the hospital of which he had charge, three having both parents leprous), none have been known to suffer leprosy. Of five cases in which a parent and child both had the disease, the development occurred towards the end of the child's adolescence, appearing at about the same time in both parent and child, the child developing the disease first in three cases, and the parent first in two cases, thus indicating common origin and not transmission from a parent to child. He classifies the types as hypertrophic, atrophic and mixed, instead of tubercular or nodular, and anesthetic or neurotio, as is commonly done. The hypertrophic forms develop most rapidly, and are usually diagnosed earlier. They ulcerate freely and promptly. The atrophic forms. develop more slowly, rarely, if ever, ulcerate, and exhibit the greatest variety of deformities. The bacilli are found with difficulty in the skin scrapings from these, but are present in great numbers in scrapings taken from the hypertrophic lesions. In the atrophic forms, the bacilli are often found at post mortem, in the nerves, leading to the affected parts. In the treatment, the part

of the body which presented the greatest amount of leprotio deposit was selected for the first series of rayings, and it was exposed to the rays at from seven to ten inches distance, and for ten minutes at a time. The distance and time of exposure were varied somewhat from time to time, and the effort was made to approach as near to the point of burning the skin as possible without actually doing so. In only two cases were the patients actually burned, and it is worthy of remark that these were the first two patients cured. If superficial burns occurred, treatment was suspended until tissue repair began. The burns showed little tendency to progress, and healed readily leaving little or no

scar.

The author submits the following explanation of the action of the ray; that, when a local lesion of leprosy is treated with the X-ray, the organisms there localized are killed, and their bodies absorbed by the system, thereby producing an immunity against the living organisms. This is practically analogous with the immunization of individuals against bubonic plague by injecting into them killed cultures of plague organisms. In the case of leprosy, he claims that we grow the culture of lepra bacilli in the human body as a culture medium, and then kill them by means of X-rays. In support of this theory, the following reasons are advanced: 1. The treament of one leprous spot on a patient produces improvement in spots at a distance from the one actually treated. 2. The cure, in the distant spots, seems to progress parallel to, and to be just as complete as in the one treated.

3. The best results seem to be obtained only when treatment is pushed to the point of killing, or beginning to kill, the tissues, which would also probably be to the point of killing the organisms. 4. Cases in which there are massive, localized, leprous deposits are most rapidly improved, as, in these cases, we have an abundant culture on which to operate, and thereby produce immunity more rapidly. 5. In diffuse, general involvement of slight degree, or atrophic character, where there are only a few scattered organisms, little success was had. 6. In two well advanced cases in which the amount of new leprotic tissue was excessively great, the improvement was marked and rapid, but followed by loss of general health, and rapid, physical decline. This may be an over dosage so to speak. (The frequency of the rayings is unusual to one used to the technique in America, but, of course, this was to bring about the "killing" effect desired. The exposures were frequently made every day, at the start, for some days, and then every other day.-Ed).

OPHTHALMOLOGY.

WALDEMAR FISCHER, M. D.

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So-called Gummata of the Ciliary Body.(N. J. Weil, Annals of Ophthalmology, Jan., 1906.)-One case, a man 25 years of age, presented a swelling fully one-half cm. in all its diameters in the upper posterior, temporal region of the left eye, the sclera did not appear much thinner in the region of the tumor. Rigid antisyphilitic treatment gave a satisfactory result. The second case, 28 years of age, presented a swelling in the upper posterior ciliary region, also of the left eye in which the sclera had become so thin this case enucleation had been advised, by that it was nearly wanting in two places. In heroic doses of potassium iodide, mercurial inunctions, sweats and hot baths the patient retained an eye with a normal contour and tension.

Clinical and Anatomical Examinations About the Influence of Radium on the Trachomatous Conjunctiva.-(Birsch-Hirschfeld, Leipzig, Klin. Monatsbl. f. Angenheilkunde, Dec., 1905.)-The inference of the radium could be clearly seen in all the cases so treated. The follicles became flattened and sank to the niveau of the surrounding conjunctiva. These changes in the follicles could be seen as early as seven hours after any exposure, but in some instances they became noticeable after one or two days had elapsed. The question, does radium act on the trachomatous conjunctiva? is answered in the affirmative in as far as the follicles disappear without increased inflammatory manifestations or scar formation. The question, can trachoma be cured by exposures to radium? is answered in the negative. Cohn's, Darier's and Selenkowsky's enthusiastic reports are to be taken cum garno salis when compared to those of da Gama Pinto, Uhthoff and the essayist's. The retrograde metamorphosis in the follicles can be demonstrated anatomically much earlier than clinically. The changes produced are very similar to those described by Hienke in Peyer's patches, the spleen and lymphatic nodes of the animals he experimented on. The changes produced by radium on the follicles are unfortunately only transitory; and as a therapeutic agent it is greatly eclipsed by the methods of treatment in vogue. In ending the author concludes: 1. In ten cases of trachoma exposed to radium three to twenty minutes a distinct flattening and disappearance of the follicles for several weeks in only one case, in the other was observed. 2. The improvement lasted nine new follicles formed after a few days to a few weeks. 3. In the cases treated by

radium the result was so unsatisfactory that the older methods employed in this disease were use to obtain a cure, even after the sufferers had been treated for months by exposures to radium. 4. The affect produced on the follicles are the same as those observed by Heinke on normal lymph nodes, the result being only temporary. 5. Only those cases of trachoma should be considered as cured by exposures to radium that present no new development of follicles for months after they have been exposed to radium 6. Radium should never be used in the immediate vicinity of the eyeball unless the necessary precautions have been taken to protect it, as anatomical changes are produced in the retina and optic nerve of animals so exposed.

The Examination of the Eye in Pregnancy.-(Polte, Klin. Monatsbl. f. Angenheilk., Dec., 1905.)-The ocular complications in pregnancy are well known, but are comparatively infrequent and do not occur in the great numbers given by some investigators, for instance Bosse who examined 124 women during pregnancy and 300 after delivery, 75% of the pregnant women had a neuritic appearance of the optic discs without subjective symptoms in the last month of pregnancy, which rapidly disappeared after delivery. According to Bosse only one-eighth of the 300 women examined the day after delivery had a normal fundus, on the second day one-fourth, on the eleventh two-thirds, and on the fifteenth day all anom. alies in the fundus had vanished. The essayist examined 200 cases before delivery and 177 cases afterward; of the 200 pregnant women 178 were healthy; the urine of eighteen contained albumen, among these there were six with eclampsia, one bad morbus maculasus, three pyelitis; 116 of the 178 pregnant women examined in the last month of pregnancy had a normal fundus. One of the six cases of eclampsia showed a hyperemia of the upper discs, which became pale the day following the premature birth. Two out of the eight cases of albuminuria had a retinitis albuminurica. The visual acuity, light sense, color sense and visual fields in the healthy pregnant women were normal. In concluding the relative infrequency of ocular complications is emphasized in contradistinction to Bosse's.

Congenital Fistula of the Lacrymal Sac.— (Prof. A. Elsching, Vienna, Klin Monatsbl. f. Angenheilk. Jan., 1906.)-So far there are about twenty cases of this interesting anomally on record. The essayist had the opportunity to observe three cases, one of which he examined histologically. These fistulae were regarded as superfluous and misplaced

canaliculi. But the cases of Vossius and Elsching prove them to be caused by an interference in development, as the extirpated fistulous tracts were built by stratified epithelium resembling that of the skin; in Elsching's case there were hair and sebaceous glands present, the abundance of elastic fibers found about the lacrymal sac and the goblet cells were absent, a clear proof that the fistula was not formed from the strand of cells which formed the sac, and later the canaliculi. In most cases the lacrymal duct is patent. Cases have been known to heal spontaneously.

Observations on Dionin. -(Chas. M. Steele, Annals of Ophthalmology, Jan., 1906.)-The field for the application of this remedy is limited. The fact that it has fallen into disrepute with some authorities is that they have employed it in conditions where other drugs are more effective. There are two conditions, however, in the treatment of which dionin surpasses any other remedy: First, in the various degrees of corneal opacities resulting from recent keratitis; and secondly, in the essayist's opinion in subconjunctival hemorrhages or hemorrhage into the anterior chamber.

Chromatic Aberration in Ametropia.-Polack, Paris, Lucerne Congress, investigated artists using as tests the pigments which they employ in their work. A slight ametropia has a decided influence on the perception of colors. Control experiments were made with de Wecker's color scale. Red becomes deeper when seen through a weak convex glass, yellow more orange, and green assumes a yellowish tint.

Blue becomes deeper with a weak concave lens, green more bluish and yellow took a slight greenish tint. The phenomenon is explained by the eye being able to accommodate exactly for one at a time of the artificial pigments of which the colors are made. Whence artists with a weak myopia might work to advantage with their myopia uncorrected. While a slight over-correction of the hypermetropic artist might be beneficial, as the so-called warm colors are important for artists.

LARYNGOLOGY AND RHINOLOGY.

HERMAN STOLTE, M. D.

Postoperative Hemorrhage Following the Removal of the Pharyngeal Tonsil.-Homer Dupuy (The Laryngoscope, 1906, No. 1) collected in an extensive research into the literature covering a period of thirty-five years, 38 cases of alarming hemorrhage following adenectomy with eleven fatalities. Causes were:

The

1. Hemophilia, contributing the greatest number of fatal cases. 2. Constitutional diseases, such as leukemia, lymhadenoma, struma, exophthalmic goitre. As local causes Dupuy mentions abnormal arterial distribu. tion, which make the field more or less unsafe to the clumsy or inexperienced operator. Thus the malposition of the left internal carotid produced a fatal issue, and the superficial seat of the ascending pharyngeal artery coursing along the junction of the posterior and lateral nasal wall of pharynx caused a lesion and very alarming bleeding. Regarding the importance of age and sex, the second decade is the more dangerous period, due to the prevalence of more vascular and fibrous tissue in the adenoids, the latter preventing the severed vessels from contracting. male sex is more afflicted by severe hemorrhage than the female, due to the fact that hemophilia prevails in the male (from 8 hemophiles with 44 fatalities 7 were male). The hemophilic tendency being transmitted through the female to the male member of the family. The fact that more fatal or severe hemorrhage occurred without the administra. tion of an anesthetic, is explained by the greater liability of instrumental injury by the increased gagging and unintentional movements of the suffering patient. In the rast majority of cases the hemorrhages occurred within the first twenty-four hours; several fatal hemorrhages occurred on the fourth day, one on the eighth day after operation. Regarding the question of checking the profuse postoperative bleeding, local applications of astringent solutions are of no value. But in constant or intermitting oozing of blood along the posterior pharyngeal wall through the nose the local application of adrenalin, or better dioxygen, will seldom fail to check the bleeding. Where there is a brisk flow of blood, spurting in character, postnasal plugging, quickly performed, is the only benefiting measure, but this fails in about 60% in hemophilia. To minimize the risk of postoperative hemorrhages we have to insist upon enforced rest in bed for twenty-four hours by giving cold drinks or chipped ice during the next few days. The author concludes as the death may occur after adenectomy by hemorrhage that the deep appreciation of our large responsibility forbids any but the specially trained surgeon to attempt its performance. Further, that it is our first duty before operation to elicit all facts relating to possible existence of hemorrhagic diathesis; further that the throat specialist has to be forearmed and ever on the alert to cope with a problem of the gravest import and alarming postoperative bleeding. This is best done by being continually

or

equipped with hemostatics and various mechanical appliances. In cases of hemophilic history where the operation has to be done, internal administration of daily 15 grains of calcium chloride for three days previous to the operation is prone to reduce the hemorrhage during operation and afterwards remarkably.

Should Tonsillar Tissue be Removed in all Cases? Why?—George Why? George W. Spohn (The Laryngoscope, No. 1, 1906) considers the the oral cavity, to prevent the entrance of function of the tonsils to stand as a guard in micro-organisms into circulation, and to arrest and destroy toxines, hence tonsillar tissue should not be sacrificed to the knife unless absolutely necessary. The pathological condition of the tonsils (hypertrophic, crypts filled with foul, germ laden cheesy material) is due to irritation by food, repeated acute inflammations, autointoxication by constipation. Such tonsillar toxine should be removed (1) when its pathologic condition cannot be cured with treatment (iodine painting); (2) when it obstructs the nares and oral cavity, or intereferes with their physiological functions. Diseased tonsils, instead of standing as a guard to arrest and destroy micro-organism, they supply a soil for their propagation and encourage their entrance into the system (acute joint rheumatism), thus failing in their proper functions, also lower ing the vitality to the general system.

Therefore removal of diseased tonsillar tissue, that needs removal, should be done early and not postponed. The mode of operation is not amputation or decapitation, but enucleation of all diseased tissue. Tonsillotomy is such a common operation in the eyes of the general practitioner that it does not have the dignified standing it deserves. If done correctly, not amputated or decapitated, but enucleated it is not an easy operation, and requires a special training and skill. In case of thorough enucleation of all the lymphoid tissue, except the fibrous portion of the gland the result will be very satisfying and lasting.

DEPARTMENT OF LEGAL MEDICINE.

R. B. H. GRADWOHL, M. D.

A Contribution to the Subject of Stigmata of Degeneration.-Dohr and A Scheele (Viertel jahrsschrift fuer ger. Medizin, Jan., 1906, Bd. XXX, Heft 1.) This investigation was undertaken for the purpose of estimating of just what value the so-called "stigmata of degeneration" are in calling attention to crime in those exhibiting these stigmata. There has been much said pro and con,

since Lombroso first called attention of the world to these signs. Lombroso called particular attention to anomalies of the skull and mouth as stigmata and worthy signs of criminality. Ganther and Wilga also spoke of the existence of stigmata in insane as well as in criminal persons. In investigations in the past upon this line much has been said and done, and yet withal, but little of consequence because the manner and method of gathering statistics has been faulty. The importance of the signs of gathering of degeneration can only be ascertained by comparing the measurements and descriptions of so many criminals with so many "normal" individuals. For this purpose habitual criminals must be selected on the one hand to illustrate the abnormal, and "honorable" people must be selected on the other to illustrate the normal. The particular point to determine was whether or not certain so-called stigmata of the mouth were more frequent in the criminal than in the honest person? For the sake of comparison, the writers selected German soldiers to represent the normal type, first because the measurements could be most easily be taken from this class, secondly because the German soldier represents an "elite class"-much more so than either the very lowest classes of German citizenship or the higher classes, being recruited from all classes. Of course the fact that a class of this kind might and does harbor some with criminal instincts must be taken into consideration in a small way in surveying the sum of these experimental observations. Again, racial characteristics are homogeneous among the soldiers, less so among the criminals examined. where foreigners were met with in some instances. The material for criminal class was selected as follows: Penitentiary at Wheleiden, 253 persons, age 16 to 30 years; penitentiary at Fulda (Cassel) 121 persons, age over 30 years; penitentiary at Ziegenhain 282 persons, age over 20 years; penitentiary at Ziegenhain 67 women, age over 20 years; reformatory at Wabern 120, age up to 19 years; house of refuge at Cassel, 168 children, age up to 14 years. This makes 1011 people examined, 101 being illegitimate, and 219 or 26% being the first-born. hundred soldiers (under-officers and privates) were examined for comparison, 20% being first-born. The particular stigmata sought for about the head and face were the caput quadratum, prominent temporal regions, receding forehead, asymmetry of the face, fissured uvulva, pointed tongue, broad tongue, tremor of tongue, deviation of tongue to right or left, deviation of nose to right or left, persistence of ear muscles, satyr-ear,

Six

variations in the lobe of ear. These variations in the lobe were divided into three kinds. Schwalbe described eight kinds, but unfortunately the present work was finished before Schwalbe's report appeared (Zur Methodik statistischer Untersuchungen uberdie Ohrformen von Geisteskaranken und Verbrechern. Arch. f. Psych. u. Nervnbknkh., 1895, Bd. 27 and so the eight classified types could into be observed. Anormalities of the jaws, teeth and gums sought for were prognathism, changes in the "normal bite" of the teeth, etc. The Caucasian races have their teeth so arranged that the normal "bite" occurs when the upper teeth slightly overlap the lower. Among certain races, the old Eyptians, the Celts and Esquimau, the incisors fit down exactly upon each other. Other points used to denote stigmata by Lombroso and Manuovier are strong developments of the lower jaw, i. e., an increase in the volume of the lower jaw. Lack of development or even absence of a chin is also pointed out by Naecke as a stigmataum of degeneration, also irregularity in the articulation or the teeth, "open bite" (mordex apertus Carabelli), diastema, variations in shape of the upper incisors; variations in the number of teeth, particularly less teeth than normal; abnormal development of the wisdom teeth; "short" teeth; erosions are said to be abnormalities found in degenerate oriminals and insane. A number of tables are given by these writers, showing exactly how often these so-called stigmata occurred among these habitual criminals and how often they occurred among the soldiers who were taken to be normal. The abnormalities were found just about as often and in just about the same degree among the normal subjects (soldiers) as among the criminals examined. The caput quadratum was alone found to be present in 1% of the criminals and not at all among the normal persons examined. Asymmetry of the face was found but once among the criminal class. It has been noted to be three times as common among Italians as among Germans. Fissured uvula was found in 0.3% of criminals and in 0.3% of the normal class. Pointed tongue was found in 1.16% of criminals and in 1.0% among normal class Deviation of tongue to right was found in 6.6% of normal and 6.8% of criminal class. Erect ears were found more commonly among the normal class than among the criminals. Satyr.ears were found in 0.83% of the normal class and 0.7% of the criminal. The anomalies of the teeth, mouth and gums were found to exist in just about the same proportions among the normal class as among the criminal. The general run of the observations seem to indicate that