fibrous tissue may remain as indurations at various parts.

From my own experience, I believe with Haig that certain foods, as meats, tea and coffee, those articles that are rich in proteids, favor the development of this trouble as they aid in the formation of certain toxins within the system.

We all are familiar with the more common forms of myalgia, as lumbago, torticollis, pleurodynia, etc., and have had our troubles with them-to relieve which we advise diet, rest, the hot pack or dry heat; give medicines internally and morphine hypodermically; rub on linimènts; resort to stropping the affected muscles. and apply the vibrator or electric light with heat; and assure our patient that the trouble is not at all serious, but to come back in two days. All this we may experience any time, but it is the extreme to which this affection may reach that I wish to report.

The following case occurred directly under my own care, and was one in which I had the opportunity of watching its progress minutely, from the rather insidious beginning to the much longer and slower termination: The patient, a young man of thirty, fairly well built and free from the taint of any specific trouble, attended an evening picnic about two miles below his home on the Ohio river. During the evening he became somewhat heated by ballplaying, and frequently resorted to the drinking of ice water, and later ate a hearty picnic lunch. On the return home his boat became involved in a race with some of the others, and, desirous for the lead, he pulled with all his strength, straining every muscle to its utmost. He noticed during his rowing a slight nausia at times, which finally compelled him to give up the oars and take a seat in the stern of the boat, throwing a light overcoat over his shoulders, for he was very warm and perspiring freely. The evening was cool and he became thoroughly chilled before reaching home. The next morning he was somewhat stiff and sore, but nothing more than he expected after such violent exercise. The following night he was compelled to be out until near midnight, and again became somewhat chilled. From now on there appeared a marked soreness and stiffness in his muscles, which gradually increased for the next five or six

days, when it reached its limit, and he was crippled in nearly every movement. During this time his appetite became impaired, tongue coated, bowels constipated, and a slight fever ranging from 99 to 99% F., which lasted but a day or two. There was a feeling of languor and general lassitude that seemed to permeate every fiber; every muscle was sore; from head to foot there was that deep-seated soreness so characteristic of myalgia, a soreness developed only on pressure, or when the muscle was thrown into clonic spasm, when it produced excruciating pain which gradually died away or was relieved by relaxation of the contracted muscle. Besides the soreness, there was a loss of power in the muscles that amounted almost to a paralysis.

The muscles of the leg, thigh and abdomen, and those of the back, neck, arm, forearm and hand were affected; even the muscles of the face did not escape, and mastication was not performed quite so readily as heretofore. Any motion that required quick action of the muscles was impossible. Moderate walking was performed with but little difficulty, but running was an impossibility, and he would sink down after the first step, apparently unable to rise. In walking, if his foot struck against any firm substance, a fall was inevitable, and when once down it was the work of several minutes to get up, and then only with the aid of a cane or some neighborly support. The act of sneezing or coughing was of the feeblest sort, the abdominal muscles seemingly offering no resistance to the expulsive effort, and it was only when he could lean or brace himself against some substance that he could get any satisfaction from the effort. He was unable to carve his food at table, and the act of dressing, simple as it was, required from thirty to forty minutes of time. The getting into his cart was attened with so much difficulty that he was compelled to resort to the plan of placing one foot upon the lower spoke of the wheel and then causing the horse to back until he was elevated to the right height. His muscles became soft and flabby and he lost in weight some fifteen pounds.

The course of this trouble was as follows: For the first few days it was progressive, then for about two weeks it seemed to remain stationary, then began to im

prove, but very slowly, and it was several months before he regained anything near his normal condition, with perfect use of all his muscles.

In the treatment nothing seemed to be of much benefit (and he tried nearly everything), except that which acted in a general way, as tonics, iron, quinine and strychnine with the hypophosphites doing the most good, with finally a trip to the seashore. Aurora, Ind.

LEG ULCERS.

BY LEWIS J. FRIEDMAN, M.D.

There are few conditions which are looked upon more lightly by the layman than a leg ulcer. These patients will usually allow this trouble to linger on, with no apparent regard, indefinitely, unless other complications set in, or as in cases seen at the city jail, Richmond, Va., and State penitentiary of Virginia, they were compelled to seek surgeons' advice in accordance with the regulations of these institutions.

In considering the etiology of ulcers in this part of the anatomy, two general causes may be mentioned:

1. Constitutional or exciting, in which class we consider tuberculosis, syphilis, varicosities, malignancy, and trophic disturbances.

2. Local causes, viz., burns, trauma, etc. Clinical varieties are of importance only for the sake of description. The ability to discover the etiological factor can not always be looked upon with ease. The case which I shall depict below will readily illustrate that.

The following are some of the tests to be tried in obscure cases to aid in discovering the exciting cause:

a. Expectant, which simply is, to treat the ulcer by simple measures, such as elevation of the limb, and the application of moist non-irritating dressings. If the ulcer be of the simple variety, the same will heal uneventfully. But, if the exciting cause be tuberculosis, syphilis, or malignancy the ulcer will persist in spite of the treatment.

b. The microscope will usually reveal the germ or fungus causing the trouble; or, if

malignant, much can be learned with the microscope.

c. The Wassermann or Noguchi test will reveal in some 75% to 80% of syphilitic cases the preinfection. This is valuable, in that more scientific treatment can be prescribed.

d. The therapeutic test must be resorted to in cases where the Wassermann test is not applicable, as in the case to be described below. This man has been taking mercury in some form before admitted to the hospital, and according to most authorities the reaction is in a majority of cases negative when this drug has been injected. The therapeutic test should always be given a trial, though the Wassermann be found negative.

CASE 1.-A. S., aged 37 years, single, colored, occupation being that of a farmer's hand makes him be constantly on his feet. He had typhoid fever in 1894 and the only sequel now apparent is thrombosis of a vein in the calf of the left leg, which can be felt as a hard cord. He contracted gonorrhea about 17 years ago, and has had no relapse since. In 1900, one wheel of a wagon passed over his left ankle, contusing the part considerably, but which soon healed. About four years later an ulcer appeared about an inch or so above and posteriorly to the external malleolus. A short while later another one developed an inch and a half above and anteriorly to the malleoli. Since their primary appearance they have never entirely healed. Almost periodically execerbations of the condition would take place, characterized by pain and discomfort. He has consulted physicians every now and then, but no apparent improvement followed their treatment. In 1908 a "little sore" appeared about the frænum præputii twenty days after exposure. An eruption appeared shortly after, also mucous patches. Considering the patient's description of the successive symptoms, I can conceive the possibility of it having been a chancre. He had been treated by a physician for a short while. The skin presented the peculiar copper-colored spots seen in colored people after an operation. In this man it was undoubtedly due to syphilides. The lymphnodes were enlarged.

Diagnosis. In narrowing the diagnosis of these ulcers we may state that primarily they were simple traumatic, but since this

man contracted syphilis they have taken a new maniere exister by becoming syphilitic ulcers.

Treatment.-The treatment in this subject was three-fold:

1. Local treatment consisted of the application of dressings moistened with a 2% solution of chloral hydrate.

2. Internally he received gr. 3/4 of protiodide of mercury three times daily, also gr. 15 of potassium iodide, increasing the dose of the latter one grain daily. After taking mercury for four days he showed symptoms of hydrargyrism. The mercury was stopped for a day. It was again resumed, but now only 1⁄2 grain in the morning and 4 grain noon and evening.

3. The last mentioned, though most important and undoubtedly the essential factor in the healing of these ulcers was rest and elevation of the limb.

Results.-Patient discharged, cured, 23 days after admission to the hospital. Ulcers have entirely healed but the scars were void of pigment. The patient was instructed to continue taking the mercury and potassium.

CASE 2.-The accompanying photograph shows an ulcer of the leg in a colored man, with a history of syphilis five years previous. The ulcer when first seen extended from the knee to the ankle, and also en

circled the leg. This condition cleared by the administration of mercuric chloride 1/30 grain, and potassium iodide 15 grains thrice aily. The skin regenerated entirely in less than a month.

I have gotten equally good results from the application of glycerin, normal saline solution, powdered iodo form, 5% scarlet red salve, and rest. Experience is the guiding star, as no two cases will yield to the same

treatment.

144 Forsyth St., New York City.

TREATMENT OF POSTERIOR OCCIPITAL PRESENTATION.

By F. R. FURSEY, M.D., C.M.

Of all the obstetrical cases that cause anxiety to the general practitioner, those in which the occiput is posterior cause the most, numerically speaking. I am sorry to say that in too many instances the anxiety does not come early enough in the management of the case to make it a useful element in determining the way in which the doctor will handle the case. These cases are all too often not diagnosed until the mother has been in labor for many hours, and often not until the termination of labor. The most essential thing for the attendant as well as the most important thing for the mother is that a correct diagnosis should be made early and no obstetrician should proceed with the case until he is absolutely certain as to the position of the child, and if he will take a little pains in each and every case he will soon see how easy it is to make a diagnosis, and each case will be much more easily diagnosed than the last.

When the doctor is called and he finds the patient complaining that the pains are worse in the back and is told that the pains have been irregular as to time, severity and duration he should at least suspect a posterior position. Then he ought to make a very careful and thorough abdominal palpation. He should examine every part of the abdomen feeling very carefully for the fetal parts. If he cannot feel them easily he should examine further. He may find them to the right of the umbilicus and a larger part which is the left shoulder is felt to the left of and below the umbilicus. The position is a left posterior, but may be

easily changed to an anterior one. A stethoscope is a valuable aid. With the back to the front the heart sounds are heard easily, but in the posterior position they are heard with difficulty. The greatest value in all the methods comes from repeated and painstaking examinations. Every case, no matter how simple it appears to be, should be examined as carefully as the difficult, so that the fingers will be educated to tell exactly what they feel.

TREATMENT: When the case is seen early and the head is not engaged by pressing the right hand on the right side of the abdomen and pressing the left shoulder to the right with the left hand, the position can usually be changed to an anterior one. Even though success is not met with at first, great patience and many trials usually result in a happy ending. But if the case goes on, still in its posterior position until the cervix is dilated enough to accommodate the hand, then the patient should be anesthetized to the surgical degree; then with the right hand intra-uterine and left hand pushing on the forward shoulder, the position can easily be changed to a correct one. It may even be necessary to push the head up until it can be turned, but generally not, because the head is slow in engaging when the occiput is to the back. Very rarely, owing to the pains being so ineffectual, will the case be seen so late that the head has descended far into the pelvis. If such has happened it always means that the head is small or the pelvis is roomy, or both. In either event, the case may be left to nature, or if there is much extension the forceps had better be used mainly to produce flexion. When forceps are being used the patient should be very deeply anesthetized and a great deal of time should be occupied in bringing the head over the perineum. If there is any laceration of the perineum this should be immediately repaired; not only the skin but the muscles of the perineum should be carefully drawn together.

If the doctor will recall the cases of occiput posterior, that he has attended and will recall also how badly the soft parts were torn and perhaps the baby's head marked with the forceps so badly that even though it heals well, yet the friends give him a very bad name owing to such marks, then he will agree that no case should be

allowed to come through in any but the anterior position, unless as I have intimated that the head be very small or the pelvis very large.

419 Paulson Bldg., Spokane, Wash.

JOURNALISTIC ENTERPRISE.

By D. L. FIELD, M.D.

With our modern facilities for printing and distributing knowledge, and the enterprise of modern journalism, everything is known as soon as thought, and much material is contributed to the rapidly increasing volume of medical literature, that adds immensely to our stock of knowledge. Great advances are constantly being made, which give us a more intelligent and successful means of practicing medicine. If it were not for the journals which mirror current thought and publish new discoveries we would be medical back-numbers.

Medical journalism supplants text-books. We gain new knowledge of diseases, and the most advanced and scientific line of treatment, only through current medical literature. If text-books were our only dependence, we would lag behind. It would take an endless and frequently published book to keep up with the times. The journals are voluminous with material to enlighten and add to our knowledge, new medicinal agents, and thereby afford us the weapons to more surely combat disease. No one, if he had nothing else to do, could read all the medical books published from month to month and year to year. He will do well enough to keep abreast with the current medical journals. They are greatly multiplied and flourish. The great majority have acquired the firmest foothold and are highly valued and appreciated by the profession. The writer can remember when medical journals were few and far between, but now they are legion. We used to read Braithewaite's The London Lancet and one or two others, and they were able journals. Now we have untold numbers as able, and exponents of advanced thought. The present medical publications which come to us every fortnight, and month, fresh with practical matter, leads us onward and opens up to us new perceptions, new views from higher and yet practical points of ob

servation, around which our horizon is conspicuously widened. By the aid of journals `we advance in knowledge and improve in practice. The present theories are far superior to the old, and the treatment is certainly far more successful, and that along reasonable and conservative lines. In the medical journals we get the counsel and experience of the most eminent and skilful as well as learned men to be found the world over. We have a host of them, instead of the ipse dixit of one man, as an author of a text-book. Such books may be valuable this year, and obsolete next year. Jeffersonville, Ind.

SOME USEFUL HINTS ON TUBERCULOSIS.

BY S. R. KLEIN, M.D., PH.D. Formerly Professor of Histology and Embyology Fordham University.

Such a wide subject like tuberculosis needs special attention to be attributed by medical and social papers. Society meetings, speeches, lectures, newspapers, etc., are reporting daily about some new work, new discoveries, new methods, new ideas, etc., on this line. Recently there was published a report about the absorption of tubercle bacilli by the skin. Profs. Nouri and Osman found that if guinea pigs were shaved in the inguinal region and then rubbed with absorbent cotton fouled with tu

berculous sputum, the corresponding lymph glands enlarged and became swollen in eight to fifteen days, and the animals died in 30 to 50 days. This may explain to a certain extent the puzzling location of certain tubercular lesions which are met with in Mohammedan and other countries where the art of shaving is somewhat crudely performed, the victim being shaved with water and a blunt razor, and the operator frequently adding his saliva as a soapy adjuvant.

As regards the presence of tubercle bacilli in the blood, Ludke was able to isolate the tubercle bacillus from the blood of consumptive patients by withdrawing 5 c.c. to. 10 c.c. of blood from the median basilic vein and injecting it into the peritoneal

cavity of a guinea pig. In three out of 14 cases tubercle bacilli were thus found to be present in the circulating blood.

For a quick discovery of tubercle bacilli in urine I presented the staining method of my own patholigical, bacteriological and chemical laboratory to the seventh International Congress against tuberculosis, held at Rome, Italy, last year (April 14-20), and it was gratefully accepted. Sorry to say that this is not the place to describe here the full method, but anybody interested in it can find and read it in some medical papers (N. Y. and Iowa Med. Journals);

Dr. Ribbert, of Bonn, Germany, in a paper read at the International Congress of Hygiene, in Berlin, states that intestinal infection does not play any great part as compared with aerogenic infection, and that tuberculosis of the bronchial glands can only be of aerogenic origin. Ravenel, of Philadelphia, on the other hand, says that the alimentary tract is a frequent portal of entry for the tubercle bacillus.

Calmette announced that if tuberculin be placed in the eye of a tuberculous subject a conjunctivitis is produced, whereas in a healthy subject there is no change. This we call the Calmette ophthalmo reaction. Experiments were carried out in young guinea pigs, tubercle bacilli being introduced by laparotomy into the stomach. Some hours later tubercle bacilli were found in the lungs, but the objection was raised that regurgitation and subsequent aspiration might have taken place, so further experiments were carried out, gastrotomy being performed, and four weeks later the œsophagus was cut at the neck and connected with the skin so that there were now two fistulous openings separated from each. other by a bridge of skin. The animals then received a feed of dried tubercle bacilli, the œsophageal fistula being closed by cotton wool and collodion to prevent regurgitation. In every animal tubercle bacilli were found in the blood, lungs and other organs, and in one animal two hours after the experiment. The result of these researches proves that virulent tubercle bacilli may be absorbed by the mucous membrane of the alimentary canal into the blood and may be deposited and possibly become latent in the lungs and other organs. 818 E. 216th St., New York City.