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atony and normal acid secretion must be due to the passing over of special putrefactive elements from the stomach into the intestines. In some cases we can find these elements directly in the stomach and in the feces. In cases of insufficient gastric digestion, fermentative and putrefactive elements can easily establish themselves in the stomach, or pass it undestroyed and in this way produce secondary intestinal disturbance as a consequence.

An important point demonstrated by Schmidt is furnished by lientery of the connective tissue. He proved to us in a way which can not be doubted, that in cases of insufficient function of the stomach there is imposed on the intestine increased work which it is not always capable of performing. Raw or smoked connective tissue the intestine cannot digest at all, and if it has once passed the pylorus unchanged, it is carried along as ballast until it is defecated. For muscle, fat and starch it is of no importance whether the stomach digestion is perfect, for here the intestinal juices can compensate. It is the connective tissue which especially becomes dangerous to the intestine. In order to be able to appreciate this fact we need but collect all the connective tissue which appears in the daily amount of the feces of one suffering from stomach trouble. By such experiments it can easily be shown, that under certain circumstances, after a test-diet, the connective tissue of raw meat is quantitatively evacuated, so that it permeates the excrement as a mesh work. As a consequence of this in gastric disturbances not only connective tissue is lost, but also the muscular and fatty tissue enclosed in it. It is normally the function of the gastric juice to prepare meat and fat for disintegration through the dissolution of connective tissue. If this disintegration is absent, the pancreatic juice can only dissolve the surface of these unreduced particles of meat, and as a result pieces of meat and fat are evacuated in the feces.

It is at once apparent that the burden of undigestible substances, as a result of primary gastric disturbance, cannot be a matter of indifference to the intestine. Here the injuries produce an insufficiency of small intestinal digestion either gradual or sudden in its onset. Whether the small intestine functionates properly or not, it cannot digest raw connective tissue and the tissue elements enclosed in it. Consequently the small intestine can no longer comply with the increased demand made on it for a long time, and the result of this is a gastrogenic diarrhea.

INTERESTING PROBLEMS IN EAR, NOSE AND THROAT PRACTICE.

ROBERT BARCLAY, A. M., M. D.

SAINT LOUIS.

Fellow of the American Otological Society; formerly Assistant Aural Surgeon, New York Eye and Ear Infirmary, New York; Aural Surgeon, Missouri Pacific Railway Hospital, St. Louis Baptist Hospital, M. K. & T. Railway Hospital (Sedalia, Mo.), Passavant Memorial Hospital (Jacksonville, Ill.); etc.

I. TO HEAL PERSISTENT PERFORATIONS OF THE DRUM-HEAD.

(Continued from page 583.)

CASE IV.--Both drum-heads extensively lacerated by explosion of nitro-glycerine. Extraordinary reparation.-E. L. S., thirty-two years of age, while serving as car-inspector, carelessly struck, with his hammer, a small, stray bottle, partly filled, lying upon the track, before him. It was subsequently determined, that the bottle probably contained nitro-glycerine. The explosion. that followed the blow of his hammer, knocked him down, and blinded and deafened him. He sustained the following injuries: superficial lacerations of all the fingers of the right hand; contusion of the forehead; several small punctured wounds of the face, and many similar ones of the legs and thighs; injection of both conjunctivae; and laceration of both drum-heads. Nine days after the explosion, these last appeared as follows: one laceration of the right drumhead, horizontally, beneath the umbo, threesixteenths of an inch long, three-thirty-seconds of an inch broad; two lacerations of the left drum-head-one, extending, from nearly the middle of the bottom of the membrane, upward, behind and close to the handle of the malleus, past the short process, across the membrana flaccida, to the canal roof; the other, from a point above the level of the umbo and behind the other laceration, downwards and backwards, across the postero-inferior quadrant of the drumhead, almost to its edge.

Both ears were treated with antiseptic remedies, at suitable intervals, until discharge from the wounds had ceased; when Blakepaper-disos were applied-in the right ear, just three weeks to a day after the explosion; in the left, three days after the right.

Thirteen days later,-which was about five weeks after the receipt of his injuries,—the patient was dismissed, with normal hearing -a whisper being audible to either ear at thirty-five feet distance; the Blake-paperdisos having been removed; and the wounds of both ears having entirely healed-a remarkable instance of rapid reparation.

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CASE V.-Drum-head ruptured, during sleep, by restless, dreaming bed-fellow. Mrs. H., about forty-two years of age, while sleeping, was suddenly aroused, in the middle of the night, by the quick impact of some large body against her left ear. This proved to be the hand of her sleeping husband-a devoted disciple of Isaac Walton-who had recently returned from a fishing trip, and who, now in Dreamland, was strenuously landing what he supposed would prove the biggest"catch" of the season.

She awoke, deafened in this ear, and with a feeling of tension and a ringing noise in it; and her own voice now had an unfamiliar sound to her.

Upcn examination, next day, a perforation, about one-sixteenth of an inch in diameter, was found in the postero-inferior quadrant of the left drum-head, almost at the level of the umbo, or lower extremity of the handle of the malleus, and about one-third its distance from the periphery. This was found in a rather thin portion of the drum-head, and bore no signs of reaction about it.

Strangely enough, the accident had happened to an ear, whose relief from the disabling deafness of "catarrh" had formerly been effected by an operation within the neighboring nares-of which, more, later.

A Blake-paper-disc, three-thirty-seconds of an inch in diameter, was, at once, applied, with instant restoration of normal hearing and natural sound of her own voice.

Eleven days later, the disc was removed from the neighborhood of the original site, the perforation having healed without leaving any mark; and the patient, since then, has not felt the slightest inconvenience from her injury.

CASE VI.-Perforation of drum-head, with deafness, persistent nearly twenty years: attack of acute inflammation; relief; closure of the perforation.-F. P. F., forty-eight years of age, applied for relief of symptoms of acute purulent otitis media, of the right side, from which he had suffered for nearly two weeks.

Following an attack of measles, twenty years ago, his right ear had discharged pus for six months; and although, until the two weeks preceding his first visit to me, there had been no recurrence of aural discharge, he had, nevertheless, been afflicted, all these twenty years, with marked deafness and occasional noises in the right ear.

On examination, the right drum-head was found greatly thickened, and perforated at about the line of junction of the postero-superior and postero-inferior quadrants, half way between the umbo and the posterior

edge of the membrane. A small nasal polypus was recognized-of which, more, later.

The discharge ceasing, under treatment, within forty-eight hours, four days were allowed to elapse; when, there appearing no probability of its immediate recurrence, a Blake-paper-disc was applied to the perfora

tion.

Three weeks after its application, this disc appeared to be still in its original site. Ten days later, it was soften with normal saline solution, and then carefully removed. The perforation was still open; now, one-thirtysecond of an inch in diameter. A stimulant was applied to its edge, which provoked discharge for about twenty-four hours. Two weeks later, a very thin Blake-paper-disc was applied. This was removed after thirteen days; leaving the perforation entirely healed, and his hearing excellent for the voice, whisper, and other ordinary sounds; when he was dismissed,

3894 Washington Boulevard.

PATHOLOGIC PHYSIOLOGY.

BYRON ROBINSON,

CHICAGO, ILL.

No richer field exists in medicine, in inductive research, or for productive scholarship than the establishing of evident cause and effect in pathologic physiology. Pathologic physiology projects physiology into the field and function of philosophy. Physiology is the most noble of medical studies. Science collects facts while philosophy arranges and predicates laws from them. The field and function of philosophy is to deal with all classes and departments of incomplete knowledge for the purpose of utilizing it for man-to prolong life, lessen suffering, and increase happiness. Pathologic physiology will aid in the partial reduction of medical practice to laboratory investigation, e.g., senility, local and general is heralded by observable cellular change-development differentiation and degeneration of its vital, physiologic process. The cell is accompanied by a cylic series of changes from embryoism through differentiation to senescence termed by Prof. Minot cytomorphosis. (1) The first stage or embryonic cell is peculiar to itself in its physiology, and if prolonged by circumscribed inclusions may become malignantly degenerated in the adult. (2) The second stage of life's cells, that of differentiation consists of two states: (a) cytostatic differentiation or the production of a material of definite and stable composition

as connective tissue, intercellular osseous substance-connective tissue framework; (b) cytodynamic differentiation is the production of substance having a metabolic function-parenchyma. (3) The third stage of life's cell is that of degeneration-senescence. Hence the laboratory investigator may yet discern the cause that determines cellular changes-embryonic, differentiation and degeneration (senescence), i.e., that pathologic physiology of life's cyclic cell and also that of disease. The philosophy of physiology at once suggests that the vital processes of cells-embryologio, differentiative, degenerative cannot be abolished, however, they can be advantageously modified. The destiny of the cell is an aggregative mould into organs-for physiologic function. The composite organ functionating as a unit make man-the animal.

Physiology or function precedes and dominates structure. Man-the animal-is the drama, the play. It calls into being, funotion, the stage accoutrements, and dramatic personae which exist and have signification to subserve the drama. The play selects and arranges the scenery, creates and determines the settings, lends coherence and sense to the sentence, furnishes inspiration and purpose to the actors. Now, it may be true in the material presentation of the play that stage furniture is the first structure element manifest, it is subordinate to the motive of the performance or play. The stage material, furniture is forgotten, lost in the functions of the play. Man's body is the stage accoutrements and personae. The drama, the play, is the physiology, the function. Interpreted this means that function determines structure, not structure function. Progressive motion in animals have traumatized, frictionized, the proximal end (brain) enticing creasing blood supply (friction) and conse. quent increase of substance arises, i.e., bumping one's head against the universe develops the brains. Lincoln's body, that is, his anatomy, his stage accoutrements are dead, however, Lincoln, master of men, his play, his physiology, his function, progresses unabated. John Brown's body, his physical stage accoutrements, is dead, but his function of liberty moves on forever, even to the latest Russian cry for freedom. The staging, the physical accoutrements of Uncle Tom's Cabin have long since disappeared. However, the motive of the play, the function of the drama which was the freeing of the black men was also ceased as the object of the play had been accomplished. The parallel between the field of music and biology or physiology is striking. Pipes and strings are the anatomy of music; but music itself, the ultimate object,

is not pipes and strings, it consists of a pleasing succession of agreeable sounds-music is the physiology of the pipes and strings. The pipes and strings-the anatomy-are made to functionate as a unit through physiology which rules anatomy. The several instruments must work in harmony-as a unit-to produce the object which is the orchestra. Sound is itself an element, unrelated, unclassified, having neither predicate nor attribute and cannot therefore be confused with music-which is the pleasing succession of agreeable sounds to the human sense and purposely designated for that object. The only functional value of sound is to be a pleasant succession.

Physiology harmonizes different structures as music does pipes and strings into a functionating unit. As the instruments in the orchestra must subserve the purpose of the musician-which is music-so the aggregative molds of cells-organs-in the body must subserve the dignified purpose of physiology, i.e., functionating unit which dominates, determines and precedes structure. We concede to our materialistic friends the physical basis of life and that function is not purely psychic in character. In the final analysis of structure or function we are dealing with the arrangement of matter, and that is structure To illustrate that function, physiology dominates structure, anatomy one need only study large non-infected pelvic perineal exudates. Not long after pelvic peritoneal exudate arises blood vessels begin to appear in the mass projecting their course through it, followed by lymph vessels and nerves as well as an endothelial covering until the jelly-like unorganized mass is a living structural unit, a functionating organism In this did not physiology dominate, detremine, percede anatomy in--yes, physiology is the central motive power of life. Darwin recognized this principle throughout his investigation of the origin of species. Through physiology he claimed he could modify species by environments that in a few years they could be scarcely recognized. By environmental influences he would modify though physiologic forces the traits or characteristics. Observe how the potent foramen ovale, modifies circulation— i.e., physiology-produce the clubbed fingers. Dr. Thomas G. Atkinson in the editorials of the Medical Standard for July and October, 1906, writes instructively and strikingly on pathologic physiology. He claims that the influences which determine structures operates from the complex to the simple, e.g., the larger functions of the body peristalsis, oirculation, cerebration are the simplified specific expressions of the multiple complex impressions produced on the body in general by

circumstances and environment, and these consequently are the determining causes of cellular structure. Physiology is the father of anatomy, of form, of characteristics, of hypertrophy. A myoma in the uterine wall or an ovum on the endometrium are the causes of uterine hypertrophy-increased blood supply has multiplied the cellular elements of the uterus. Physiology or direction of excessive blood to the uterus has determined the multiplication of cellular structure. And thus the amphioxis and similar animals that superseded and repeated his structure bumped their heads against the world's physical forces developing the four skull vertebrae and multiplying their cerebral cells by enticing blood due to the cerebral trauma. The Japanese have long bodies and short legs because they do not use the legs sufficiently to secure blood. Sitting on chairs would entice more blood for large legs. The lessons to be drawn from these views are that structure has no power to modify itself. It is perverted function that alters structure-pathologic physiology is the father of it. Again, Dr. Atkinson claims that perverted function, pathologic physiology operates from the complex to the simple. Pathologic physiology finally terminates by registering itself as altered adjustment of cellular stricture in accordance with the perverted function at issue. Structural changes as a rule are the final responsive reaction of cell arrangement to the pathologic physiology having their origin in the complex relations between organism and environments and operating through the less and less complex physiologic systems of the body. The skillful and scientific physician can discern the origin and course of pathologic physiology and apply the appropriate advice drug or scalpel first to correct the function, and second, to correct the structure.

The chief duty of a physician is to correct function.

As nine-tenths of illness is so-called medical and one tenth so-called surgical, practically the sphere of a physician's influence is limited to the field of pathologic-physiology, which lies between normal physiology and pathologic anatomy-the zone of pathologic physiology.

The common functions of viscera (sensation, peristalsis, absorption, secretion) do not perform uniformly throughout the same visceral tract, and hence demand special attention in physiology, e.g., secretion is more prominent in the proximal end (cerebrum) of the tractus intestinalis, while absorption is more pronounced in the distal end (sympathetic). These views should be borne in mind when observing pathologic physiology.

In excessive secretion there is not only an expenditure of energy, but also a loss of material from the body. Physiology deals. with the sources of energy and the transformation of energy. The practically wise physician seeks to trace through the deviating functions the source of erroneous energy.

In the consideration of physiology or pathologic physiology the nervous system must be considered a presiding genius, e.g., food within the duodenum incites both the liver and pancreas to secret through a nervous mechanism, for it appears that if bile and pancreatic juice become mixed in Vater's diverticulum or immediately on arrival within the duodenum the power of the succus pancreaticus is doubled. It is well to know for practical therapeutics (pathologic physiology) that adrenalin-a product of the adrenal medulla circulating in the blood appears necessary for the excitation of any nervus vasomotoris. The thyroid gland manufactures some substances-thyroiodinwhich aids in the proper growth of body tissues, and also for the normal discharge of the cerebral functions. The fetus during gestation secretes some substance which aids in enlarging the mammary gland. The ovary secretes a substance which preserves sex and nervous characteristics. Hence with increasing knowledge of physiology we may be able to isolate these substances-adrenalin, thyroiodin, ovarian secretion, secretions of pregnancy which induces mammary hypertrophy, etc.-and with their isolation possess a list of therapeutic messengers at our command which will correct the pathologic physiology of bodily organs. With broader knowledge of physiology present therapeutic nihilism will be replaced by rational therapeutics which rests on physiology, the solid ground of nature.

The results from the study of the four grand common functions of viscera (sensation, peristalsis, absorption, secretion) must be the rock and base of our authority in pathologic physiology.

RABIES PREVALENT. -Babylon, Long Island, has been considerably alarmed over the prevalence of rabies among the dogs in that section. The board of health convened in special session and passed stringent resolutions requiring all dogs owners to keep their dogs under close watch; unless this order is obeyed the dogs will be shot. In New York City also the unusually large number of cases continues, 30 cases having been treated within a month. Cures have been effected in all cases that have been treated.

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PROBABLY the first question that confronts the young physician, after he has left the hospital, is the choice of location. The young man without capital naturally thinks of a salaried position. Very few such are available, at least at the very outset. Older physicians occasionally employ assistants, but the supply is so far ahead of the demand that it is almost never that anything, like an adequate salary is paid. Five or six dollars a week is the usual wage, or merely privileges of the use of office and instruments, in some cases. Not rarely, the assistant pays his employer.

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The ratio of physicians to population in the United States, is about the same that of white to red blood corpuscles, 1:600. Unless there are peculiar circumstances it is well to consult directories regarding this point. It is also well to remember that almost the only opportunity to enter at once into a self-supporting practice, is found in the country or in some factory distriot of a city.

Unless there are peculiar circumstances, it does not appear that previous acquaintance either hinders or helps a physician, although there is a general tendency for a man in any line of activity to maintain about the level of his family. If he rises above or falls beneath this level, it is on account of personal strength or weakness.

A similar principle is that, generally speaking, it is wise to remain in the climate and social or political area to which one is accustomed. Unless there is some physical reason to the contrary, most men enjoy better health in the climate to which they are enured, and in going from city to country, or from South to North, or vice versa, considerable readjustment of views and habits is required and before this has taken place, unintentional but serious errors may be committed.

Having chosen the geographic location, there remains the choice of a residence, which is governed largely by individual tastes and means. Without regard to immediate necessity, that is supposing that the young physician has enough capital to last three or four years, by which time he should be earning a fair income, there is a difference of opinion as to whether it is best to seek a neighborhod comparatively free from competition, so as to build up a rather large prac

tice in a few years, or whether it is best to locate among established physicians and in a part of the city which can be regarded as a satisfactory permanent residence. Each method has its advantages and its disadvantages; some fail and some succeed by either method Even in comparing ultimate degrees of success, it is difficult to determine how much is due to the method and how much to personal factors.

In some cities the question soon arises whether the young physician should seek a career as a teacher. Twenty or thirty years ago, teaching positions involved comparatively little labor, yielded fair direct returns and were almost a prerequisite to a consulting practice. Thus, ambitious men who could not get into existing schools, often organized competing schools. It would require too much space to trace the various evils aud counter-evils that developed, and to relate the history of the reaction from the educational system of that time. Today, medical teaching is becoming more and more a specialty, and while the gratification of the very highest ambition in medicine still demands a teaching position, it demands one of the proper kind and even longitude enters into the matter to a considerable degree. Positions that develop Peppers and Oslers are few and are practically out of reach of the vast majority, even of the best physicians. Excepting positions of honor in really great universities, it is doubtful whether, at present, medical teaching is of service in advancing a man in his strictly professional work and the tendency is more and more toward the choice of teachers for didactic ability and toward the restriction of teachers to teaching as a profession apart from practice. At any rate, it is no longer wise and, indeed, scarcely possible, to organize a medical school as an advertisment, or to accept a position on a faculty, except for the immediate benefit derived.

Somewhat the same thing might be said regarding hospitals and dispensaries, though not in the same degree. Whereas appointments to the latter were at one time nearly restricted to medical teachers this is no longer the case unless in a few cities. The profession recognizes a distinction between teaching the rudiments of medicine to undergraduate students and the devotion of time to advanced problems in medicine, which virtually constitute a faculty of teachers of the profession. Hospital and dispensary work is in many ways a decided help to the worker and yet even men who hold such positions are rather returning to the method of a couple of generations ago,

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