ROBERT H. DAVIS, M. D. Radio-Therapeutics of Ringworm at the Municipal Laboratory of the City of Paris at the Hospital of St. Louis.-Saboraud (Brit. Jour. Derm., June, 1906) gives an exhaustive account of the methods in vogue at the above mentioned institution. His treatments extend over such a wide series of cases (about 4,000 a year), and over such a length of time (since the latter part of 1903), that the results are reliable, and we seem to have reached at last a specific for this so chronic trouble. Unfortunately, the apparatus required is not easily obtainable in this country, and considerable skill is necessary to get the proper results. He uses a dynamo of three-fourths horse power to work a statio machine of twelve discs of 75 centimeters diameter, and a speed of 950 revolutions a minute. In the circuit between the condensers of the static machine, and the two poles of the tube, is interposed a spinter metre (a kind of ball electrode), the separation of which measures the spark in centimeters, and the resistance inside the tube to the current which traverses it. A small, self-regulating tube, of only 8 centimeters diameter is employed. The tube is surrounded, at a distance of 3 centimeters from its wall, by an incasement, or shield, of "strong sheet iron lined on its inside by a thick layer of insulating ebonite." This covering is open to the tube on the side that does not give out X-rays. On the other side, opposite the point of emergence of the X-rays, this covering is pierced by a hole to which is adapted the whole series of localizers. The localizers are metallic cylinders, all of the same length, but of different diameters. Their variations in size are, of course, necesitated by the variable dimensions of the patches on the scalp which it is desired to X-ray. The length of the localizers is the same always, and, is such that the skin, closely applied to the external orifice of each is 15 centimetres from the anticathode. His experience shows that, in the treatment of ringworm at any rate,

the quality of the ray employed makes but little difference. The quantity given is the main, almost if not quite the only, point of importance. "Even if it is admitted that there are different categories of X-rays, with different qualities, all are depilatory, and all equally so when equal quantities are compared." He uses, as before stated, a static machine, and extremly hard tubes, making ten to twelve on the radio-chromometer of Benoist. By this combination he secures the maximum working in the minimum time. The period of exposure can be reduced to six or seven minutes, but it has been found to be better to let the sitting last from ten to fifteen minutes according to the condition of the atmosphere, tubes, etc. If a coil is used, a moderate voltage and a reduced ampèrage is required (60-70 volts for an average of 4 ampères in the primary current). In regard to the all important question of quantity, he shows conclusively that the X-rays should be measured at their exit from the tube, and not as has been attempted in terms of the current that produces them. Holzknecht's pastilles were produced with this object. The pastilles used by the author, and invented by himself and Dr. Noiré, are based on the alteration caused by X-rays in Bristol paper, coated with an emulsion of platino-cyanide of barium, in collodion with acetate of starch. These pastilles ought to be placed at half the distance from the source of the X-rays, or anticathode, that the skin is. In other words, they should be placed at 7 centimeters from the anticathode. The tube

also should not be so large that the pastilles would have to be placed at a less distance than 2 centimeters from the glass. The pastilles, while under the influence of X-rays, should be covered by black paper, or if not, the working should be in semi-darkness, for daylight delays the color changes in the platino-cyanide of barium. His X-ray radiometer has a standard tint, which he calls "tint B." When the pastille, placed at 7 centimeters, has taken this tint, the skin, at 15 centimeters, has received exactly the quantity of X-rays necessary to cause "the complete depilation of the region without irritation, without dermatitis, and without compromising the ultimate regrowth of the hair." Naturally, the time of exposure varies from day to day, and even from hour to hour, owing to variations in the source of the ray, atmosphere, tube, etc., but the assumption by the pastilles of the proper tint shows when the requisite amount has been given, and, in this trouble at all events, the therapeutic effect is directly dependent on the amount, and not on the quality, of the X-ray used. It is very important to place the pastile at

exactly 7 centimeters from the anticathode. (Whether the above technique has not been accurately carried out, or for some other reason, eminent rayists in this country have failed to get such flattering results with Saboraud's pastilles. Both Stelwagon and Pusey have given adverse reports on their use during the last year.-Ed.) The author says that, with his experienced nurses, he has never had a case of dermatitis in 7,000 exposures. He thinks that the factor of idiosyncrasy in the occurrence of an X-ray dermatitis is accordingly neglible. In comparing the color the pastile has assumed with the standard tint, the comparison should be made by daylight. If one patch only exists this can be thoroughly treated at a single exposure, but if it is necessary to depilate the entire scalp, a series of ten or twelve exposures is necessary, but there need be no time interval between them. All is accomplished at one sitting, each area treated being covered with a lead disc, retained in place by an elastic band, before the next area is exposed. About fifteen days after the treatment the hair falls out with the slightest traction, their root ends being atrophic and sharpened like the point of a needle. On the eighteenth day, the head is washed with soap, rubbing and pulling out with the fingers all the weak hair. The roots of trichophytic hairs are the last to fall, and they must not be allowed to remain, for they can infect new hairs. Daily washings with soap remove them. By the thirty-fifth day the head, thus treated should be entirely bald. From the first day of operation, the entire head is anointed daily with R tr. iodin (fresh) 1 part, alcohol (80%) 9 parts. The head thus treated remains bald about two months. Then the new hairs begin to appear. The new growth ought to be complete in four months. When the color B has been exceeded the regrowth may be retarded for a month or six weeks longer, but baldness that remains after six months is permanent. Overexposure may occasion a cicatricial atrophy which will cause a definite absence of regrowth, or, in place of the old hair which is smooth, a growth which is crinkled and woolly may occur, or the new hair may be like the old, but much thinner. Insufficient application results in atrophic hairs, sharpened at the ends, and in the exclamation-point forms of alopecia areata. In these cases depilation may be pushed far enough for a cure to result. In other cases, diseased hairs may remain, and the whole process have to be gone over again. A second exposure should not be made on the same place, within a month.

At

Traitement de la Syphilis Par la Voie Rectale.-Audry (Annales de Derm. et de Syphligraphie, March, 1906) reports a series of thirty cases treated in this unusual fashion. Mercury is given in suppositories of the grey oil, which are prepared as follows: As many times four grammes of cacao butter as one wishes suppositories are taken, and softened by heat. When the cacao butter loses its transparence by cooling, the gray oil is incorporated into it, and it is allowed to cool in moulds. cool in moulds. The gray oil being 40%, in order to bave the suppositories contain gr. .01 of mercury, .025 gr. of the gray oil should be added to each suppository; for an .02 gr. of mercury suppository, gr. .05 of the gray oil must be added to each, etc. The gray oil is prepared with mercury, oil of vaselin, and lanolin. For adults the dose is gr. .03, for children gr. .015 to .02 is sufficient. One suppository is used each day, the dose being generally given in the afternoon. It was tried giving two a day, but the patients then complained of burning and pain at the anus. the end of a month, an intermission of four or five days is made, and then the course begun over again. The results claimed are as follows: (a) tolerance is at once established. In a few cases diarrhea occurred, but the author does not consider this due to the suppositories, since, always after a mild purging, the treatment could be recommenced, and there was no more trouble. (b) There was no pain, or tenesmus, or straining. There was never a trace of erythema, or fissure. (d) Except for a slight gingivitis in one case that had been salivated previously by treatment before entering the hospital, nothing abnormal presented presented itself in the mouth. The mouth was always kept as aseptic as possible, however. (e) The simultaneous administration of iodide of potash occasioned no inconvenience, nor untoward symptoms. (f) Long treatments are apparently harmless, as a child of three and a half years was given more than 100 suppositories, gr..015 daily, in less than four months without the least inconvenience either local or general. (g) As to efficacy, he considers it equally to any form of treatment administered by the mouth, with the exception of bichloride of mercury in large doses. In general, the symptoms are modified by the fourth day just as by the usual methods. The action is particularly quick and certain with respect to lesions of the ano-genital region, and the bucco-pharyngeal. Violent, generalized, papular syphilides were quickly influenced. two cases, during the treatment, a violent, papular outbreak occurred. Both these patients were alcoholics. They were put on injections of the gray oil, and the outbreak re

(c)

In

sisted even this manner of treatment up to five injections. They should not then be counted as pointing to the inefficacy of the suppositories. Another case exhibited an

early return of the trouble, but a similar relapse, in this case, occurred after a second apparent cure from a course of rubbings and injections. In general, the action of the suppositories seems to be quite as good as that of inunctions, or injections. As regards the indications for adopting this form of treatment, he says that the cases reported are as yet too few to enable him to give specific rules, but, in a general way, in grave cases, he would advise injections or inunotions; in cases not so urgent, the rectal method offers a means of mercurialization which seems to be perfectly sufficient and satisfactory. It can then be considered applicable in the class of cases usually treated by the mouth, and can be substituted for that method when digestive troubles appear, and consequently hinder gastric and intes. tinal absorption. He considers it quite possible that this method will be the best for the treatment

of infantile syphilis, and closes with the observation that "there is a real utility in achieving and possessing a new method of administration of mercury, which has proved for itself efficacy, coupled with simplicity and an unassailable harmlessness."

HYPERTROPHY OF THE BRAIN.-J. H. Haberlin, Pawtucket, R. I. (Jóur. A. M. A., June 30). reports the case of a child, aged 2, dying in convulsions in which the apparently symmetrically enlarged brain weighed 1,712 grams, (533 ounces). The membranes were not adherent, there was no flattening of the convolutions, no disproportionate increase in the size of the ventricles and the gray and white matters were developed proportionately. Clinically, the case could not be differentiated from hydrocephalus.

INFANTILE SCURVY. --Alice M. Steeves, Boston (Jour. A. M. A., June 30), reports two cases of infantile scurvy observed by her and describes the condition. She believes that the disorder is common in large orphan asylums and similar institutions and in examining the mouths of 180 girls at the Lancaster Industrial School she found 20 per cent with thickened spongy gums, saliva purulent and mucoid, and with the nose, mouth and throat inflamed. These girls all complained of having rheumatic pains, and while the condition, she says, is not strictly scorbutic, it seems to her to suggest a field for investigation.

SOCIETY PROCEEDINGS

ST. LOUIS MEDICAL SOCIETY. Meeting May 26, 1906.

The society had as its guests at this meeting* Dr. Maurice H. Richardson, of Boston and Prof. Dr. Duehrrsen, of Berlin, who addressed the society.

Dr. Richardson spoke on "Further Observations on the Diseases of the Biliary Tract with Especial Reference to Diagnosis.

land between medicine and surgery, and He said that the subject lies on the bordershould therefore interest a general society of physicians and surgeons. President Eliot, of Harvard, has said that there is nothing like the joy of good, and the essayist thought there was nothing like the joy of diagnosis. One would think that since the first operation for gall-stones was performed many years ago by Botts, that the matter has progressed so far that little remains to be learned about it. A great deal, it is true, has been learned in the past twenty years about this subject. One fact stands out of all this knowledge that has been gained, that the earlier the diagnosis is made, the sooner the operation should be performed. The least is known of the diagnosis of gall-stones in their earlier manifestations, together with the fact that little is known of the diagnostication of stones of typical or unusual form. Until recently the observation of such cases has depended upon autopsy findings or upon spontaneous rupture. Even the autopsy findings have taught but little because the pathologist who finds gall-stones thinks that they have rested in the gall-bladder without ever having produced symptoms. The finding of gall-stones in connection with other operations upon the abdominal viscera have shown some relation

ship between cause and effect.

The symptoms of gall-stones are well defined when there is a passage of gall-stones out of the bladder, producing "colic." This is pathognomonic, especially if the passage of the stone is slow enough to cause jaundice. Pain in the gall-bladder simulates pain in the gall duct only when the pain lasts a long time. In the earlier forms of gall-stone disease before the gall-stone has made its way into the ducts or duodenum, the symptoms are trivial and not understood. Later, when the irritation of the gall-bladder mucous membrane ensues, with ucleration, thickening of the walls of the bladder, etc., there is a regular sequence of events. There is a great variation, however, in the way in which impaction of stones is felt.

There are certain ways in which the gall

stone manifests itself that is characteristic: when the stone passes from the gall-bladder into the duodenum. It is said that in many cases in which gall-stones are found in the cystic duct and common duct, there is no history of pain and other symptoms. The wide variation which has been found in many cases shows that the history should have been taken more carefully and the diagnosis could then have been made. All symptoms in the right hypochondrium are suggestive of gallstones. Because the patients do not complain of excruciating pain, it by no means follows that there is no stone present.

There is a definite relationship between cause and effect and a thorough exploration will determine the pathologic picture. In demonstrating gall-stones found in the course of other operations, Dr. Richardson said that he was able to follow the history of gallstones. Such experiments cannot but convince one that all gall-stones produce symptoms from their beginning until their final passage. The professsion should be impressed with the difference between the slight danger of removing gall-stones in their early formation and the great danger of removing them in their later manifestations where there has been thickening of the gall-bladder, or ulceration or impaction in the ducts.

For all practical purposes it can be said that the nidus of gall-stone is in the gallbladder and that the micro-organism of some kind is usually the cause. Between the time of the aggregation of the crystals making up the gall-stone and its final passage, there must necessarily ensue a long period of time. If gall-stones are found many years after typhoid fever, and if one accepts the thought that the typhoid bacillus acts as the nucleus of the stone, then the life history of the stone might be said tc date from the attack of typhoid fever. The size of the stone is not a thing by which you can judge its age. The consistency of the stone is a more important thing by which to judge its age. Gall-stones usually have a long age before they begin to offend. A soft stone easily crushed between the fingers may be usually regarded as one of very recent formation.

Symptoms referable to the gall-bladder do not always mean the presence of gall-stones. In some cases inspissated bile will cause symptoms in this region. What are the sources of evidence upon which to base a diagnosis? One source is the information given by the history of gall-stones found in the course of other operations. Such operations are operations for malignant disease of the alimentary tract in men, operations upon the pelvic organs in women. Symptoms are accounted for in some cases by other condi

tions, i. e., malignant disease of the intestines with gall-stones impacted in the duct. The speaker said that he often thought the severe pain found in the left thorax in these cases was due to gall stones. He said that he had found gall stones floating free in the gall bladder in cases of malignant disease of the uterus.

In another case of fibroids of the uterus, he found a gall stone that produced symptoms of pain in the upper abdomen which did not seem to be gall-stone colicky pains.

The general result of the speaker's observations was that gall-stones either cause definite symptoms which are diagnosticated correctly, or that they cause indefinite symptoms which are considered to be due to faulty digestion. Occasional pains accompanying intestinal peristalsis should be suggestive of gall-stones. Stones too large to pass the cystic duct may give rise to a suspicion of their existence by causing cholecystitis. In many cases the stone fill the entire gall-bladder. He said that he had felt gall-stones firmly grasped by the lower fibres of the gall-bladder which might give rise to intermittent colicky pains. The general result of observations by Dr. Richardson was that the cases vary extremely. He mentioned a case of ulceration of a stone through into the duodenum where there was no history of pain.

The very early symptoms of gall-stones are usually described as "indigestion, "gastralgia, with no jaundice. The most that can be said about this symptom is that it is a kind of discomfort. The pain is therefore the most constant symptom of stone, either a spasm or the consciousness of a discomfort in the right hypochondrium or in the left hypochondrium for which the patient seeks some relief by means of some simple remedy. A experience with such cases should make one skilful in diagnoiss. The pains of gallstones might be said to come with a "regular irregularity," or rather with an "irregular regularity. When after painstaking and prolonged history-taking, there is a recital of such symptoms, making one suspicious of gall-stone, then the surgeon can be of much service. If on top of the history of discomfort there is a history of spasmodic pain at times, and rise of temperature indicating infection in the gall-bladder, then the suspicion of the existence of gall-stone disease is strong indeed.

The diagnosis of gall stone elsewhere than in the gall-bladder would seem to be a more simple matter than the diagnosis of stone in the gall-bladder, yet in many instances the surgeon finds stones impacted in the cystic or common ducts where he never suspected such a state of affairs, this without

jaundice. Where there is an impaction and a damning back of bile, filling the gall-bladder and making it an almost solid viscus, this can be felt beneath the border of the ribs. Yet the speaker has seen cases of impaction without symptoms. The error in making the diagnosis therefore consists in failing to elicit a careful history. There ought to he There ought to he a description of having had some pain or discomfort. The signs of gall stone in the cystic duct are usually characteristic. There are symptoms dependent upon the closure of the duct. Where there is no distension, the exact diangosis is a matter of exploration. In the presence of stone in the common or hepatic duct, the most common symptom is jaundice. Yet there are many cases without jaundice. If the history fails to show jaundice, then the history is at fault.

It is argued that an irregularly-shaped stone could be forced into the duct, allowing bile to flow by, yet Dr. Richardson doubted the explanation. The error in not noting jaundice in such cases has been said. to be explicable on the ground that the stone passes quickly into the duodenum, without stopping the flow of bile, yet the speaker did not think this probable.

A careful search of the stools without finding a stone is a flimsy means of basing a diagnosis that there is no stone in the gall ducts. The speaker said that he had found many stones in the common duct with thickening of the walls of the duct, indicating that they had been there for years. In all cases there was pain in one form or another. When pain comes on in paroxysms, whether there is jaundice or not, there is a suggestive of gall-stone.

Symptoms of gall-stones are divided into two categories, the one comprising those cases giving a typical history, the other comprising those cases giving a variety of symptoms so great as to surpass belief. The majority of gall stone cases do not present a typical picture. Obscure symptoms occur in the very beginning of the gall-stone disease. Peculiar conditions are met with in the biliary passages. The field of gall-bladder surgery will probably never be cleared up. The

essayist said that he has worked in this field for the past twenty years, and with each succeeding year he has become more and more convinced that diseases of the biliary passages are many and obscure in symptomatology. After many attacks of biliary pain and jaundice a stone may be found impacted which sometimes allows bile to escape. There must be some difference in the character of the pain from the passage of the stone into the duodenum and the pain of a stone moving on from place to place of its impaction.

The pain is therefore the most important point and the cause of the pain in gall stone disease can be obtained by reconstructing the history of these cases. The cause of pain in cases in which the gall stone is found in the gall bladder is found in muscular spasm. Where the stone passes to the duodenum, there is pain with or without jaundice. The fact that the bile is completely obstructed is not the cause of pain because total obstruction of bile found in malignant disease of the biliary passage, without pain. Where the tone is impacted, the symptom will be similar to those already suffered, due to the efforts of the muscular fibers to push the stone along. In case there is infection in connection with a thickened gall-bladder, etc., this must have something to do with the pain. Occasionally there is necrosis of the gall-bladder with perforation into the alimentary canal. In such cases of giving way of the gall-bladder walls, there may be no pain of a beginning peritonitis.

What are the indications for surgical interference when the gall stone is suspected to exist? An experience with many cases teaches us many things about this subject.

When a man has a few cases of gall stone colic recover without an operation, he begins to think that there is plenty of time to wait in all cases. A strong suggestion of gall stone practically means gall stone. In practically all cases where Dr. Richardson suspected them, he found them. The less severe the symptoms are, the less severe are the indications for operation, and when the indications of their existence are severe, then the necessity for operation is imperative.

DISCUSSION.

Dr. N. B. Carson thought that the discussion belonged more to the medical man than to the surgeon, because most of these cases are first seen by the medical man and after the diagnosis is made, the surgeon undertakes to give treatment and confirm the diagnosis. He was particularly struck by Dr. Richardson's statement of his interest and joy in diagnosis. There is a tendency on the part of the surgeon to trust too much to the medical man for a diagnosis, and in this tendency there is a trend towards mechanical work by the surgeon. Many of these cases present symptoms of stomach trouble. Recently Dr. Carson operated upon a woman who, imbued with the Roosevelt idea, had had twenty-three children, and from whom he had removed 146 gall stones from the gall-bladder.

She gave

very little indication of the presence of this mass of gall stones. Another case mentioned by the speaker was one in which the gallbladder was highly packed with gallstones