explored with a needle in four different directions to exclude the possibility of fluid causing dislocation of the heart; no fluid was there. The liver was much enlarged and the jugular veins were pulsating; 250 cc. of blood were withdrawn. During the bleeding the respiration dropped to 36, the pulse to 120, and it became regular and fuller, and the temperature fell to 102 F. The heart apex retracted to the fifth space, midway between the anterior axillary and nipple lines; the boy began to perspire, and fell into a quiet sleep for several hours.

Bleeding under these circumstances is done to remove a physical obstruction to the circulation by emptying the over-distended right heart, and making it possible for it to contract upon its contents, and thus aid in keeping the blood circulating.

Complications.

So far as preventing complications is concerned, I know of no means of preventing the development of an empyema or a pericarditis unless it be by the general" measures of treatment above outlined and the regular use of dry cups or leeches locally on the chest over the parts of lung which show advancing congestion as well as over the precordium when, through increased activity of the heart, there is evidence of beginning congestion of the pericardium. Then the local application of four to six leeches, followed by the ice bag, has been the means of limiting the spread

of the disease.

As to the prevention of meningitis, the regular use of an alkaline nose and mouth wash throughout the course of the disease tends to keep the germs away from the cribriform plate and to keep the mouth of the Eustachian tubes and accessory sinuses clean and open and thus prevent the spread of infection directly to the meninges or via the ear.

So far as the prevention of the development of a nephritis is concerned, the regular use of alkaline drinks and occasionally the rectal administration of a considerable amount of sodium bicarbonate solution tends to render the urine non-irritating and so to keep the kidneys in good shape. I have seen no good come from the administration of urotropin in these

cases.

Serums and Vaccines.

I have not yet seen any good result from the use of any antitoxic serum or pneumococcus vaccine, neither have I seen any convincing report of their true value, though we must all hope and look for some such agent to be developed for the treatment of this disease.

I sometimes think I have seen improvement and eventual recovery follow the hypodermic use of nuclein in profoundly toxic cases with relatively low leucocyte count.

I have on record a series of somewhat over three hundred cases, treated on these general principles-mixed cases, hospital and private practice, ranging in age from one year to eighty-nine. I have not separated them as to age, previous habits or previous state of health. The death rate in all of these cases together was 10.1 per

cent.

The Von Pirquet Tuberculin Test and its Interpretation.

By W. ROY DILLINGHAM, M.D., Health Officer Graham County,

MORLAND, KANSAS.

plained about the results they were getting Recently some physicians have comfrom the Von Pirquet test for tuberculosis.

I am of the opinion that the fault is in and not in the test itself. I believe that the the proper interpretation of the reaction test is one of the most valuable in our tuberculosis work, because it is of value not

only in making our diagnosis but is of still greater value in making our prognosis.

The test to be of value must be applied properly. In the first place it is a mistake to use alcohol or any antiseptic after scrubbing up the skin of the arm. In fact, I question the advisability of even washing the arm unless the skin is actually filthy, and then only ordinary toilet soap and warm water need be used. I use the little scarifier sold by all dealers and follow the instructions as given by Von Pirquet. A single drop of old tuberculin solution is placed on the outer side of the arm and, about three inches below, another drop is placed.

The scarifier is held lightly between the thumb and forefinger, and placed against the skin of the forearm midway between the two drops of tuberculin. The instrument is turned between the thumb and forefinger with the result that the superficial skin layer is scarified. One needs to make but two or three revolutions of the scarifier to obtain results, and only slight pressure is needed. On the first turn one feels the edge of the scarifier "slide" over the skin; on the second, one

feels it "take hold," and that is the time to stop. The point scarified midway between the two drops of tuberculin is to be the control. After making the control, one next scarifies the skin under the drops of tuberculin by placing the scarifier in each drop of tuberculin and scarifying as in the control.

Properly dressing the arm is important also. The glycerin in our solution of tuberculin keeps it from evaporating and, if the sleeve is pulled over the arm, the tuberculin is rubbed off. One should take a narrow strip of gauze with four or five thicknesses and lay over the scarifications, hold it steadily so that it does not move while adhesive strips are put on to hold it in place.

Now from this procedure one is to get one of two results, and the interpretation of the result is the important thing. Any time after twenty-four hours the arm is to be examined; but forty-eight or seventytwo hours will not be too long to wait in case one cannot see the arm sooner. The reaction may be positive or negative. A positive reaction is one in which there are red areas, varying in size and in deepness of color, around the scarified points where the tuberculin was applied, while the control shows no such reddening. The positive reaction may be very slight, very marked, or anywhere between the two. A negative reaction is one in which all three places remain the same.

A positive reaction means simply this: that somewhere in the body there is, or has been, a tuberculous lesion and that immunizing bodies or antibodies are present. In a case well advanced with the destruction of considerable lung tissue, a positive Von Pirquet with a wide area of deep, dark red around each point of application of tuberculin is a favorable sign, and gives that patient a good prognosis because antibodies are being formed in large quantities.

If one has a mild reaction and all other signs are absent, the patient has no pulmonary tuberculosis: he has had a tuberculous focus somewhere, some time, and the antibodies are still present in sufficient numbers to give a mild reaction. A negative reaction means, therefore, one of two things: either there is no tuberculosis or there are no antibodies. If there be no other signs or symptoms of pulmonary tuberculosis and the Von Pirquet is negative, the patient has no tuberculosis and

has never had it. If one finds signs which make him suspect a possible tuberculosis and then gets a negative Von Pirquet, there is no tuberculosis. On the other hand, if all the signs and symptoms of a marked pulmonary tuberculosis are present and the Von Pirquet is negative, it means that not enough antibodies are being formed in the body to overcome the infection and to neutralize the toxines and that the prognosis is, therefore, very unfavorable for the patient.

A positive reaction is but the cutaneous manifestation of the whole process of immunization. The toxic material, i. e., tuberculin and the immunizing bodies come in contact on the skin where the results can be plainly seen. The very fact that the patient has had an attack and had completely recovered with an immunity to tuberculosis is the reason he has a positive Von Pirquet even though the test be made years after the attack.

Angina Ludovici.

REPORT OF A CASE.

By CLAUDE E. REITZEL, M.D., HIGH POINT, N. C.

This designation dates from 1836, when Ludwig, a Stuttgart surgeon, described a series of submaxillary phlegmons of much severity.

Butler's Diagnostics of Internal Medicine has two very short paragraphs on this subject. He says: "It is a rare disease."

Johnson's Surgical Diagnosis has one good paragraph on this disease. He says: "If unrelieved by very early incision, the whole side of the neck becomes a deep mahogany red, as hard as a board; the constitutional symptoms threatening, and the local symptoms of interference with respiration alarming."

Osler has one paragraph and styles this condition "Cellulitis of the neck," or "Ludwig's Angina." He says: "In medical practice this is seen as a secondary inflammation in the specific fevers, particularly diphtheria and scarlet fever. It may occur idiopathically or result from trauma."

Felix Semon holds that the various acute septic inflammations of the throat-acute edema of the larynx, phlegmon of pharynx and larynx, and angina Ludovici—“represent degrees varying in virulence of one and

the same process." So does Nelaton state. Caille's "Differential Diagnosis and Treatment of Disease" says it "frequently proves fatal on account of laryngeal edema and suffocation. In urgent cases tracheotomy is indicated, and the usual deep-seated abscess is opened from the outside."

Bryant and Buck, in their "American Practice of Surgery," give the best and most elaborate description of this pathological affection. They say: "The outset of this inflammation is usually sudden, being characterized by dyspnea and dysphagia; and severe constitutional reaction may follow. When incision is delayed widespread suppuration and sloughing are apt to take place, and death may occur within a few days from sepsis. Prognosis is grave. Of the early cases reported, the mortality rate was 43 per centum."

My patient, a young man 19 years old, had suffered pain in superior sternal region for two days, when he called me to see him. I found him prostrate, with coated tongue, fever 103 degrees F., severe headache, and distressing pain in left side of neck. Root of tongue elevated, sore, and protruded. Swallowing became almost impossible. Head rather extended.

'At this visit there was no special local manifestation except the pain. Under the usual treatment for such symptoms, the patient progressed from bad to worse. This patient had been well previous to this attack.

On the third day a small swelling, very tender upon pressure, appeared on the left of the median line about midway between the submaxillary bone and the clavicle. The symptoms enumerated above became very severe, throat became edematous, and dyspnea and dysphagia were marked. The condition became serious, and the family greatly alarmed.

I called Drs. Burrus and Mendez, my associates, in consultation, and we agreed this was a case of angina Ludovici.

There was no local evidence of suppuration, but the left supra-clavicular region near median line being most suspicious, we anesthetized patient, made an incision, and carefully dissected deep down until a very large abscess was found. This was drained through counter openings in which tubes were inserted. The patient made complete recovery in about three weeks.

The microscopical examination of pus showed the streptococcus pyogenes.

Simplified Neurology.

Fourth Paper: Localization of Lesions of the Nervous System.

By HANSELL CRENSHAW, M.D., Neurologist to The Hospital for Nervous Dis

eases,

ATLANTA, GA.

In localization of organic lesions of the nervous system the first step should be to determine whether the trouble is in the brain, the cord, or peripheral nerves. Let us therefore examine a few selected casehistories with a view to determining first whether the lesions are cerebral, spinal, or peripheral, reserving for the present our opinion as to the more specific location of the lesions.

Mrs. B., aged 38, widow of a physician, presented among others the following symptoms: (1) slight paralysis of the entire left side of her body, evinced particularly by the dragging of her left foot as she walked, by her inability to use her left hand and arm well, and by the feeble grip in her left hand; (2) inequality of the pupils; (3) greatly increased knee-jerks, especially the left; and (4) some spasticity (stiffness) of the left leg and arm. The patient was well-nourished, and there was no appreciable wasting of the muscle nor impairment of the mental faculties. The muscles of the left arm and leg reacted normally to electricity and there were no areas of anesthesia. The patient was not in the least hysterical, and the gradual onset of her trouble pointed unmistakably to organic disease.

Hemiplegia, or paralysis, of one-half of the body is nearly always due to a lesion in that part of the brain, called the internal capsule, where the nerve fibers from the motor areas converge on their way to the brain-stem and cord. Since all the motor neurons destined to supply the opposite side of the body are closely gathered together in the internal capsule, a single alone, can be responsible for a paralysis of small lesion at this point, and at this point voluntary movements throughout one-half of the body. A lesion lower down, in the cord, would be likely to involve the motor tracts supplying both sides of the body because the two tracts lie close together in the cord. Moreover, a lesion involving only one lateral half of the cord would produce the so-called Brown-Sequard paralysisparalysis of motion on one side of the body

and paralysis of sensation (anesthesia) on the opposite side because the sensory fibers cross in the cord at various levels while the motor fibers cross in the medulla.

If the peripheral neurons had been involved, there would have been marked wasting of the muscles, and there would have been diminution instead of exaggeration of the deep reflexes, the knee-jerk, for example. Each tendon reflex is dependent upon the integrity of a reflex arc consisting of a sensory neuron passing from the tendon to the posterior portion of the cord and motor neuron passing from the anterior portion of the cord to a healthy muscle after having "touched fingers" in the cord with the sensory neuron. Any lesion in this arc must diminish or abolish the tendon reflex of the muscle concerned. Contrawise, a lesion of the upper neurons which lie in the cord and brain always exaggerates the tendon reflex. These upper motor neurons are supposed to exercise a cerebral controlling influence over the lower, or peripheral, neurons; and when this control is suspended from any cause, the lower arc loses its normal smooth action, so that muscles of opposing groups act together causing stiffness and the tendon reflex overacts when elicited. Furthermore, had the peripheral neurons been involved in Mrs. B.'s case, the paralyzed muscles would not have reacted normally to the Faradic and Galvanic currents.

The inequality of the pupils was further evidence of disturbance in the brain; and had this lady presented palsies of the ocular muscles, these, too, would have indicated encephalic involvement. Also disorders of speech, of mentality, or of equilibrium would have implicated the brain. Clearly, then, the lesion in the case of Mrs. B. is located, not in the cord nor peripheral nerves, but in the brain.

a

The next case is that of Mrs. R., robust-looking married woman 38 years old. She came to the hospital upon a stretcher because of her inability to walk. Examination revealed a complete spastic paralysis of both lower extremities. Both knee-jerks were greatly exaggerated, ankle clonus was marked in both feet, and likewise the Babinski phenomenon. There was no loss of sensibility in the paralyzed limbs or elsewhere in the body, but there was considerable numbness and burning in the paralyzed parts. An important feature of the case was the well-nourished condition of the muscles of the lower extremi

ties. The electrical reactions of these muscles were not tested, but had they been tested the muscles would have reacted normally. The mind of the patient was clear and there was no hysterical factor in the case.

The well-nourished condition of the muscles, together with the increased action of the knee-jerks in this case, exclude the peripheral nerves from blame. And the fact that both lower extremities were paralyzed simultaneously practically excludes the brain as the seat of the trouble. Then, too, the absence of any headache, paralysis of the ocular muscles, or mental derangement is against the idea of brain. involvement. In this case the lesion is in the spinal cord. Paraplegia, or paralysis of corresponding parts of the body on both sides, is rarely caused by lesions elsewhere than in the cord.

Mrs. S., aged 25, married, presented among others these features: (1) flaccid paralysis of the muscles of the right instep; (2) exquisite tenderness to touch on the front of the right leg and foot; and (3) some wasting of the muscles of the leg. This patient was a very small woman and her trouble followed a terribly difficult confinement, during which the head of the child exerted long and intense pressure in the pelvic canal. In this case the intense pain forbade testing the tendon reflexes, but doubtless they were impaired.

The absence of spasticity, the presence of muscular atrophy, and the history of the case point conclusively to neuritis of traumatic origin. If instead of a history of trauma there had been a history of longcontinued indulgence in alcoholic beverages, alcoholic neuritis would have been the diagnosis. But the flaccidity of the paralysis, the wasting of the muscles, and the diminution or abolition of the tendon reflexes is a triad of features which, aside from the history of the case, is a sufficient foundation upon which to rest an opinion that the seat of the lesion in a case like this is in the peripheral neurons.

Next Month-Localization of Brain Lesions.

Irrigation of the bowel with weak solutions of calcium and potassium chlorides are recommended in the treatment of pleuritic effusions and tuberculous ascites. Authorities differ as to the strength of solution. necessary, but the theory is that the chlorides remove the sodium ions from the blood and tissues.

SEPSIS.

By JOHN U. FAUSTER, M.D., PAULDING, OHIO.

The old division of sepsis that was formerly taught; namely, pyemia, sapremia and septicemia, mentioned in the order of their virulence and importance, is of interest now only as a matter of medical history, and should be in the same class and category as the former classification of pus-"laudible," etc.-that prior to the age of asepsis was so prominent. so prominent. Further, whether the diseased condition is produced by streptococci or staphylococci is equally unimportant since sepsis is caused by a micro-organism which, in the particular case under treatment, is known as the "pyogenic coccus." True enough, the former (streptococci), distribute themselves more and are inflammatory in their action; while the latter (staphylococci), produce more circumscribed faci; yet for obvious reasons they cannot and need not be separated. Both produce constitutional disturbances and both may be found side by side in the

same case.

The aim in treating sepsis is to destroy the pyogenic organism or, if that cannot be accomplished, to prevent them from multiplying and thus inhibit their growth.

I

The etiology need scarcely be mentioned. The disease is caused by the introduction of the infecting organism by wounds of the skin or of the mucous membrane. The mucous membrane of the uterus is a fertile field for their invasion and, indeed, other mucosa are equally susceptible. recall a case of tonsillitis occurring in my practice some years ago that was followed by a fatal sepsis; no doubt this infection took place in the tonsil. To enumerate more at length the various ways and channels through which an infection may take place, the part played by the lymph channels would be a long procedure and wholly unnecessary.

The period of incubation varies from a few hours to several days.

Pathology.

Suppuration may or may not occur at the point of infection. Valvular lesions, the result of endocarditis, are common. The blood shows marked changes; red blood cells being materially reduced and the white cells increased except in the very severe or very mild cases, in which conditions there is a leucopenia. The serum becomes watery

and the hemoglobin reduced in proportion to the reduction of the red blood cells; in the severe cases deformation of the red cells is frequently seen. What is of greatest importance-please let me emphasize thisis the fact that cocci can be demonstrated from the blood of a septic patient.

Symptoms.

There may or may not be a period of malaise, pain in the limbs and joints, dullness, headache, the patient usually attributing these manifestations to "catching cold" or some other minor ailment. The symptoms gradually increase, with chilliness and chills, followed by an elevation of temperature, anorexia, nausea, vomiting and occasionally diarrhea. What more frequently happens is to have the disease ushered in with a decided chill, followed by a high temperature, severe headache and pain, the patient restless, unable to sleep and in some cases depending upon the infection-with profuse sweats. The pulse is quick, not well sustained and, let me add, this is the barometer to guide the attendant as to the gravity of the disease, some cases of sepsis showing no great elevation of temperature. Referring to another case in my experience, an appendicitis patient who refused to be operated upon until after the appendix had ruptured, the abdominal cavity became filled with pus and, though the patient was decidedly septic, the maximum temperature was 99 with a feeble, rapid, thready pulse. After evacuating the pus, the temperature rose to several degrees above normal, gradually subsiding as convalescence advanced. Examination of the urine will frequently show albumin.

Diagnosis.

This is based upon the clinical historychill, high temperture, rapid pulse and the laboratory findings in the blood.

Prognosis.

The course and prognosis depends largely upon the causative factor: its duration may be brief or may last for weeks; some cases succumb in 48 hours, while others run a long steady course only to end fatally, while still other very severe cases will recover after a protracted siege. In all diseases prognosis depends upon the patient's power of resistance or vitality, if you choose to call it such, but in no disease does this particular characteristic play so important à part as in a septic infection. a Treatment.

Some cases are amendable to surgical interference, but rarely is the matter so eas