we believe we have had several cases which we mistook for chancroid.

We took the trouble to trace back our recent cases, and they came, we believe, from one single woman, and the victims say there were several men similarly affected who patronized her in her depraved and unnatural practices. She was fifty-two years old and she had Vincent's angina, which promptly cleared up after two doses of diarsenol and a gargle of peroxide.

Hereafter we shall look with suspicion on any cases of "chancroid" which develop a fetid odor.

Gangrene of the penis is often a serious matter, and the erosive balanitis is very prone to become gangrenous.

We believe this disease to be definitely mastered, but the trouble is it is not correctly diagnosed. Doctor, keep your eyes open for erosive balanitis.

Proposed Increase in Periodical Postage,

The War Revenue Law passed by the last Congress changes the present flat one cent per pound rate on magazine postage (second class) to a zone classification ranging, according to distance, up to ten cents per pound. This will be a heavy burden on an already stressed industry, and of course it will have to be passed on to the subscriber, else the magazines can't live.

This law goes into effect July first, and an effort is being made before the present Congress to have the law amended. We trust our readers will use their influence in this direction.

Some increase in magazine postage (second class) is inevitable and right. But we do object to the ZONE PLAN, as do all publications. We feel that the zone system will work a real hardship on people in the parts of the country far removed from the publishing centers.

Physicians in the Eastern States, close to the large medical centers, in the most populous part of the country, where medical societies also are capable of greater efficiency, are far less dependent upon medical journals than in the more sparsely settled States. Yet it is exactly these sparsely settled parts of the country, away from medical centers, where practiIcally the one facility available to the physician for keeping abreast with the advance of medical science, is the medical journals of national circulation-the journals that will be most injuriously affected by the zone system. If circulation in the out-lying districts means a loss to the publisher, such circulation will certainly be restricted, if not cut off altogether.

We feel that an increase, but at a flat rate, would be a much wiser and fairer way of dealing with the problem.

Coming in March.

A Live Issue

Editorials

"The Treatment of Influenza from Various Angles" will be the subject of the leading editorial. "Two Methods in Case-Management" and "Drug Treatment of Narcotic Additions" will also be features.

Original Articles

Orthopedic Diagnosis, by Prof. James K. Young, is a subject of coming importance to us all, owing to what the war will produce in the way of cripples that can be made useful by orthopedic methods. Orthopedic diagnosis involves much, but the methods are readily mastered, as this paper shows.

Granular Urethritis; Its Frequency and Importance, by Noah E. Aroustam, M.D., shows that 45% of all cases of chronic urethritis are of the granular type; and they do not yield to treatment except under proper technic, which is outlined.

A Comprehensive Study of Water Supplies, by Prof. R. B. Smith, will be begun in March and concluded in April or May. A highly informative paper somewhat out of the usual, distinctly practical and one that should be widely read.

Scarlet Fever, by A. B. Cloak, M.D., is a clinical study full of suggestion and practical advice.

The Eye in War Time, by Prof. John J. Kyle, authoritatively outlines what the profession should know of this subject. Major Kyle bases this paper upon his experience in camp and the reports from Europe.

The Diagnostic Histotomy, by B. G. R. Williams, M.D., briefly deals with surgical pathology from the laboratory standpoint.

The Sexual System a Dominant Factor in Humanity, by Benj. E. Dawson, A.M., M.D., is a clever analysis of the subject from a clinical angle. There is much to learn from this paper.

Belief and Error: Their Effect on Behavior, by Prof. J. Madison Taylor, announced for February, was unavoidably held over for March.

The Treatment of Gonorrhea and Its Complications, by J. Henry Dowd, M.D., and begun in February, will be concluded in March.

Constructive Reform

The Therapeutic Faith Without Works is Not Always Dead, But Remedial Works Without Faith May Be Dead analyzes the question of therapeutic nihilism vs. drug obsession.

Medical Economics

The Necessity for Democracy in Medicine raises the question whether we should hohenzollernize or radicalize the profession; and the answer is: Neither one, but there is need for more democracy in medicine.

Why So Many Men Fail to Make Good as Rectal Specialists, by Atwater Lincoln Douglass, M.D., is an inside story of vital interest to the would-be specialist.

Many Fine Papers are Coming. Doctor, Why Not Tell Others of the Council?

The following papers are contributed exclusively to this journal. Republication is permitted if credited as follows: MEDICAL

COUNCIL,Philadelphia.

We are not responsible for the views expressed by contributors: but every effort is made to eliminate errors by careful editing, thus helping the reader.

Assistant Professor of Clinical Neurology, Columbia University; Associate Consulting Neurologist St. Luke's Hospital, etc.

New Hope for the Tabetic.

Tabes dorsalis, or locomotor ataxia, is rather hopelessly regarded. This paper shows that the disease is not diagnosed sufficiently early for treatment to be effective; and it deserves very careful study.-EDITOR.

TH

HE PRESENT-DAY treatment of locomotor ataxia by means of mercury and salvarsan is so efficacious and so universal that an early diagnosis of the condition is most important.

To the general practitioner and the ordinary observer locomotor ataxia is credited as beginning with difficulty in locomotion and especially trouble in walking. As a matter of fact, the difficulty in walking and the general ataxia are symptoms of what is termed the second stage of this disease rather than symptoms of the initial stage. Long before the patient notices any difficulty in walking, any stumbling, any trouble with his feet, other symptoms have appeared. It is to call the attention of medical men generally to this fact that I am going to enumerate these early symptoms, describe them, and suggest measures which will enable an early diagnosis of locomotor ataxia.

There are five leading symptoms in particular with which locomotor ataxia inaugurates its attack on the nervous system. These are:

(1) Pain.

(2) Paræsthesiæ.

(3) Bladder Symptoms.

(4) Blindness.

(5) Gastric disturbances.

Pain.

The most common and usual way in which the disease begins is with the appearance of pains. These pains are invariably described as sharp and shooting in character, short in duration, and in distribution particularly limited to the legs and thighs. They occur in paroxysms and last but a few seconds. The patient will describe them as of the utmost violence and will feel that during their prevalence he is unable to do anything or take his attention away from

the affected limbs. These pains were described at some length in the December number of this journal in 1916, together with their management and treatment.

Paraesthesiae.

The second early symptom with which the disease begins is that known as paræsthesia. These paræsthesiæ are exceedingly common and occur in fully seven-eighths of the cases. Their distribution is very much like that of the pains; they almost invariably begin on the inner side of the thighs and extend down the leg to the feet. Later on in the disease, as the condition progresses, they involve the upper part of the body and include the arms and hands. They | are really not disturbances in the parts in which the lesion occurs but have their origin in the nerve roots which enter the spinal cord. They are, therefore, evidences of irritation in the sensory nerve fibers. Parasthesiæ, therefore, are referred pains, being referred not to the actual site of origin but to the periphery, the terminal portion from which the irritated fibers arise. In the hands they are felt first in the middle fingers and inner half, and then in the ends of the fingers. In the feet they are felt on the soles and along the little toes. In the trunk they are felt as a squeezing sensation; patients often describe the feeling as that of a cord tied around the waist, or of being squeezed by an iron corset. This condition is known as the girdle sensation. One of the most common ways for these paresthesia to make their appearance is with the sensation of roughness on the soles of the feet. Patients state that they feel as though they were walking on cotton or velvet. Other ways in which the paræsthesiæ are described are as tingling, burning and boring sensations. They are therefore, very often mistaken for the burning so common in neurotic conditions. Many a cause of locomotor ataxia is diagnosed as rheumatism because the patient complains of sharp pains, and many a case of locomotor ataxia is diagnosed as neuritis because the patient complains of burning pains.

Bladder Symptoms.

Disturbances in the action of the bladder are a very common manner for the disease to begin. Starr states that it was present in 80 per cent. of his cases. In many spinal affections it is the first symptom and in locomotor ataxia is especially common. The

mechanism of the bladder is poorly understood, and therefore, it is difficult to explain the reasons for the various kinds of bladder disturbances which arise in spinal cord conditions. The most common ways in which bladder disturbances manifest themselves in locomotor ataxia are twofold; either there is marked difficulty in emptying the bladder or there is great difficulty in starting the stream. It is not clear just what is the pathological condition in these two cases. The sensory fibers running to the bladder originate in the lower part of the spinal cord, and probably any interference or any sclerosis of that portion of the cord will affect the impulses transmitted to the bladder walls and thus in turn interfere with the function of that organ. Thus, there may be a complete lack of sensation so that no sensations are transmitted from either the mucous membrane or the muscle fibers of the bladder to the cord. In this event it is possible for that organ to become greatly over-distended; this over-distention becomes a form of paralysis, and prevents a complete emptying. In this condition there is very frequently a retention of a certain amount of urine in the bladder which undergoes decomposition, resulting in cystitis.

Blindness.

Blindness is much less frequent as an initial symptom than either pain or bladder disturbances. It does not occur in more than 5 per cent. of the cases. It very often does present itself in the very beginning of the disease. The pathology is that of a primary optic nerve atrophy. This condition may reach the stage of partial atrophy and so remain for a number of years or may advance completely and be one of absolute blindness. Many of the blind beggars on the street are cases of locomotor ataxia. It is a curious fact that those tabetics who suffer from optic nerve atrophy with resulting blindness rarely present symptoms of ataxia, whereas very ataxic patients rarely give any evidence of involvement of the optic nerve.

A lesson to be learned from the appearance of optic nerve atrophy is that constant ophthalmoscopic examinations should be made, not only at the beginning of every case, but also throughout the course of every case. Blindness may not only present itself early but may also develop later in the disease, even in the stage of paralysis. If it begins in the early stage, the patient begins to complain of hazy eyesight and difficulty in recognizing colors. Erb states that practically one-fifth of all cases of locomotor ataxia, some time in their course, develop a certain degree of optic atrophy. A curious fact about it is that the atrophy is generally bilateral, affecting both eyes, although the temporal half of the field of vision is more often affected than the nasal half.

Gastric Symptoms.

Another method of onset in locomotor ataxia is by the development of symptoms referable to the stom

ach. This is present in about 10 per cent of the cases, being more frequent than eye symptoms but not so common as bladder symptoms. The method of onset is threefold-pain, simple vomiting or gastric crises.

The pain may be either severe in character and located in the abdominal region, or merely an increase of the sensation of constriction. The pain, as shown by the appearance of the patient, may even go to the point of prostration.

The second manner of onset, that of vomiting, occurs independent of meals and is constant for several days. It may at first consist of undigested food, but as it goes on simply mucus and bile. The vomiting is as exhausting and distressing as are the attacks of pain; in either the pulse may become rapid and feeble.

By far the most common form for the gastric symptoms to develop is that known as the gastric crisis. It is also the most common of all the many crises which occur in locomotor ataxia. These crises are really a combination of the pain and the vomiting. Their course is typical; their onset sudden. As a rule the patient has a sensation of pain or of constriction. The pain may be located in the abdomen and radiate towards the heart or the shoulders. Within a few hours retching may begin, which in turn is followed by violent and persistent vomiting. The combination of the pain and vomiting persists for days, the patient is unable to retain anything. loses his appetite, so that the condition may go to the point of great exhaustion, the tongue becomes dry and the pulse irregular. I have known these attacks to last eight or ten days; instances have been reported where they have persisted for weeks. Those cases which are subject to gastric crises have constant recurrences, so that a patient who has had one or two of these attacks must look forward to a series throughout the disease. It is a curious fact that the vomiting gives no relief.

Charcot brought out two or three points which can not be too strongly emphasized. The first is that the gastric crises of tabes occur most often early in the disease and last for a long time. Secondly, as the disease advances and develops, these crises are apt to cease spontaneously.

The Diagnostic Syndrome.

I have called your atention to five symptoms, any one of which may inaugurate locomotor ataxia. Of these five, the pains, the symptoms referable to the bladder, and the stomach disturbances are the most common. Blindness as an initial symptom is more unusual. The general practitioner is constantly called upon to treat attacks of pains in the legs, difficulty in passing water, and digestive disturbances, which he rarely or never thinks of as being the initial symptom of locomotor ataxia. These cases may go on for months, treated as rheumatism, tumor or cancer of the bladder, and acute indigestion, and it

is for this reason that I am calling attention to the prevalence of these five symptoms.

It is by no means infrequent to see a patient in the wards of a hospital, diagnosed as acute indigestion, to whom test meals have been given and in whose case it has been impossible to prove as present either a cancer or ulcer of the stomach, and yet who has absent knee jerks. It has never occurred to any one to look for a spinal cord condition as being the cause of the vomiting. Cases of indigestion cannot be too thoroughly examined. Practically every one of these patients who presents one of these five symptoms will prove the diagnosis by either a blood or spinal fluid examination. The blood Wassermann

milk and eggs can be given and sufficient opium to reduce the prostration and to stimulate the heart. A symptom which gives great distress in these cases is that of thirst. It will be found that minute and rapid doses of very hot water, such as teaspoonsful every fifteen minutes, will relieve this condition much more readily than ice or cold water. Resort should also be had to local external applications, as mustard and hot-water bags applied to the stomach.

A Simple Apparatus

for

every patient, and a spinal puncture ought to be made a routine part of every examination of every neurological case. The practical question which will next suggest itself is what can be done to help these cases?

Treatment.

The treatment of the symptoms of pain and paræsthesia has been fully described in the December, 1916, issue of this journal and therefore will only be touched on here in a cursory manner. The one drug which will ameliorate the pain is salvarsan. Added to this the physician has a long list of anodynes and external applications. The bladder symptoms are exceedingly difficult to help. Probably salvarsan and mercury will do as much if not more than local applications and bladder irrigations. However, it is well to try both.

For the blindness we are practically helpless. There no longer exists any contraindications for using salvarsan in these cases of blindness. Along with it vigorous treatment by mercury and general tonics should be used.

The gastric disturbances can best be managed in two ways-one by treatment between the attacks and the other by treatment during the attack. The treatment between the attacks is even more important than that during the attack. The patient, between the attacks, should be given as much and as nourishing food as possible in order to prepare his physical economy for the severe test which will come. If he meets the gastric crises well nourished and in good condition, he will not only resist it better, but he will also be able to shorten its duration. Once the attack has started any number of remedies may be tried. What helps in one attack may not be of any value in the next, so that gastric lavage is important and will often give temporary relief. Small doses of oxalate of cerium, together with bicarbonate of soda, is of value. If the attack persists and the patient is unable to take any nourishment for several days and shows evidences of great prostration and heart failure, two things can and should be done-feeding by rectum, and the administration of morphine hypodermatically. Nutrient enemata consisting of

By DEWELL GANN, JR., M.Sc., M.D., 1602 Spring St., LITTLE ROCK, Ark.

Simplified Surgery.

All simplification in surgical technic is a great factor in wartime, and at all times to the general-practitioner surgeon. This valuable paper offers definite aid in intrathoracic and head surgery.-EDITOR.

Y WAY of introduction let us mention a few

problem of artificial respiration and its maintenance by means of intratracheal insufflation, a very old principle but a method whose clinical practicability was first advocated by Meltzer and Auer1, in 1909. Andreas Vesalius2 demonstrated, in 1559, that he could prolong the life of an animal when the thorax was open by blowing through a tube which had been introduced into the trachea. In 1667, Robert Hook" proved to the Royal Philosophical Society that the respiratory movements were necessary only to bring about a fresh supply of air to the lungs, contrary to the belief at the time that the movements of the thorax were necessary for the maintenance of life.

With the above pioneers as starters, the effectiveness of the principle of intratracheal insufflation anesthesia has gradually been improved, until at the present writing this means of administering anesthesia, when indicated in operations about the head of an intrathoracic nature, is well thought of by those accustomed to its use.

In the attempt to maintain life by means of artificial respiration we are chiefly concerned with the establishment and maintenance of an unobstructed passageway for the afferent and efferent currents of air and a sufficient volume of air to supply the necessary amount of oxygen and remove the excreted carbon dioxide.

Essentials of the Apparatus.

Many apparatuses have been devised for this nurpose but all embody the same basic principles, name

ly: 1, a source of air pressure; 2, a pressure bottle; 3, an ether bottle equipped with a valve for regulating the amount of ether administered and 4, a safety valve to indicate a sudden rise of pressure in the lungs.

The essentials of the apparatus described below are shown in Fig. 1.

Description of Fig. 1.

1 represents a piece of rubber tubing six inches long and one-quarter inch in diameter, and this diameter holds for all rubber tubing; 2, glass T-tube; 3, rubber tubing six inches in length and thumb set screw; 4, rubber tubing fifty inches in length; 5, rubber stopper perforated in three places; 6, 7 and 8, glass tubing, each tube six inches in length and of a diameter to fit the rubber stopper five; 9, pressure bottle, capacity six liters or less if desired; 10, rubber tubing twelve inches in length; 11, rubber stopper with two perforations; 12, glass tubing eight inches in length; 13, wide mouth bottle for mercury, capacity two hundred and twenty-five cubic centimeters; 14, glass tubing four inches in length: 15, rubber tubing six inches in length; 16, rubber tubing twelve inches in length; 17, glass T-tube; 18, rubber tubing eight inches in length; 19, rubber stopper with two perforations; 20, glass tubing nine inches in length; 21, ether bottle, capacity five hundred cubic centimeters; 22, glass tubing four inches in length; 23, rubber tubing eight inches in length; 24, rubber tubing five inches in length; 25, thumb set-screw; 26, glass T-tube; 27, rubber tubing fifty inches in length; 28, metal or glass Y-tube; 29 and 30, soft rubber catheters, size each 23 F.

With these specifications, seventy-five cubic centimeters of metallic mercury, two hundred and forty cubic centimeters of sulphuric ether, a pump and an intratracheal tube, properly adjusted, the anesthesia is ready to be begun.

Intubation and Administration.

The patient is first deeply etherized. While this is taking place the motor is started and the efficiency of the pump tested. A mouth gag is then properly placed, the tongue pulled forward and the head slightly lowered. By means of a suitable laryngoscope the tracheal orifice is brought into view. A gum catheter is then inserted between the vocal

cords and beyond until an obstruction is met. The tube is then withdrawn about an inch. This procedure completed, the rubber tubing (27) is attached to the free end of the catheter. If the thumb set screw is open the ether in bottle (21) acts as a valve and the unadulterated air passes from bottle (9) through rubber tubing (16), (24) and (27) to the trachea. When the operator is desirous of giving ether the thumb set screw on rubber tubing (24) is gradually closed. This forces the air through tubes (17), (18) and (20) so that it bubbles through the ether. It then passes out through tubes (22), (23), (26) and (27) to the trachea. When the thumb set screw is properly adjusted for a given case it will be found that the anesthesia is complete and even and can be kept so with very little effort on the part of the operator.

If the case is a difficult one to intubate and the operator is to do anything but intra-thoracic work, the rubber catheters (29) and (30), Fig. 1, may be passed, one through each nostril, into the nasopharynx. The end of the rubber tubing (27) is then slipped over the tail of the metal Y-tube (28). This affords a complete narcosis, but in this event it is often necessary to immerse the ether bottle in a pan of hot water.

In case the pump is not self-regulatory and the current of air is too strong to be accommodated by the apparatus without the constant use of the safety valve, the necessary amount of air may be allowed to pass through rubber tubing (3) to make the proper adjustment. A foot pump may be attached here to be used in case of an emergency.

An apparatus similar to the one described above was used for experimental purposes in collaboration with Drs. W. D. Gatch and Frank C. Mann in the Laboratory of Experimental Surgery, Indiana University, and its efficiency seems well established. Later, for practical purposes, it was used in the Howard A. Kelly Hospital, in collaboration with Dr. R. M. Lewis, and at present is in use in the Laboratory of Surgical Technic, U. of A., Medical Dep't.

Conclusions.

It is realized the apparatus is a very crude one; but since its efficiency is well proven it is being offered in the hope that the uninitiated in the mechanical principles involved in the administration of intratracheal anesthesia may see it and at some future period, when we do not have the best at our command, it may prove of use as it stands.

The mercurial safety valve, per se, is only of use in indicating that the danger point has been reached. Should one be desirous of knowing the exact amount of intrapulmonic pressure at all times, a mercury Utube may be substituted.

Description of Fig. 2.

Fig 2, is a semidiagrammatic sketch showing the adjustment of the parts and the direction of