kidneys, is approaching acidosis, and does not take an inhalation anesthetic well; why there is much nausea and slow recovery from anesthesia in some cases and death in others; why children in particular, who are near acidosis, always pass into that state and die unexpectedly. 慌慌慌 EYE SIGNS IN NITROUS OXID ANESTHESIA A. H. O'Neal, in the American Journal of Surgery, points out that in giving nitrous oxidoxygen anesthesia the observance of the eye is of equal importance to the pulse, respiration, blood pressure and color of the patient. Indeed, he says, to him it has become a more reliable guide than any of these. In watching the eye we note as the patient becomes unconscious, its continual oscillation, the contraction of the pupil and the lack of conjunctival anesthesia. The next change to be noted is the lack of oscillation of the eyeball with conjunctival anesthesia. The eye muscles relax and the cornea is often seen in a dependent position. Here it is that the operation should be commenced. It is this loss of oscillation and conjunctival anesthesia (because the two are synchronous) which should guide us. If anesthesia is deepened the pupil will dilate. If anesthesia is lightened and the pupil still remains dilated and the eyeball oscillates, we have then a condition of shock which will show an oscillating eyeball with a dilated pupil. The operative work should then be temporarily suspended. Before asphyxia occurs to any great extent you will notice the oscillation of the eyeball ceases, and I think it unquestionably gives us reliable information. As the zone of operative anesthesia in nitrous oxid is but fleeting and narrow, O'Neal offers this sign of the non-oscillating anesthetic eyeball as the most reliable guide in its administration. ME VE VE MOVING PICTURES IN MEDICINE The International Journal of Surgery states that at the present time moving pictures have taken so firm a hold upon the public, that this method of presentation has impressed the medical profession with its value as a teaching medium. In the earlier days the work was somewhat crude owing to the fact that the operator did not realize that a certain technic was neecssary to produce a smooth-running picture. The advantage of working slowly but positively, keeping the field clear for the camera, replacement in position where a picture was interrupted, the value of using artificial light, which properly illuminated the field, and avoiding as far as possible the deep shadows and blackened whites of the skin all these factors in the achievement of good results have been attained only after painstaking care and careful co-operation 'on the part of the surgeon, the camera man, and the director. Without a technical knowledge of the possibilities and limits of photography, many have failed to realize that in black and white work the skin, which is pink, is not a constant white, but prone to take the dark tinge of the reds, while blood takes on all the negative phases of black. Again the shiny surfaces due to the reflection of wet areas invariably tend to intensify the impenetrable black of the reds. For these reasons, if moving pictures are to accurately visualize the motions of the operator, he must realize that the camera cannot follow the finger and must content himself with portraying only what is comparatively superficial. If many of the camera men realized this, we would doubtless be spared many feet of film which are absolutely useless, besides being trying on the eyes of a wearied audience. While the present tendency of surgical and medical moving pictures has drifted somewhat toward the spectacular, it is well to bear in mind that merely going through the technic of an operation is tiresome and becomes monotonous. Operations must be humanized. The patient is human, and the preliminary steps which are a part of an operation, including taking the patient to the operating room, the administration of ether, etc., prepare the audience for human things. The patient then becomes an entity, and the rapidly flying fingers in the subsequent procedure have a definite meaning. The commercialized moving picture producers leave no stone unturned to produce this very result, and if handled carefully, there can be no medical objection. There is a field even now for the surgical scenario writer who has an exact and carefully studied technic, which he can offer to any competent operator to carry out. All of this may be objected to on the ground that we are departing from the strictly scientific presentation of surgery and entering the field of entertainment and instruction. This we freely grant. We believe this is a very live field for moving pictures. After viewing many surgical moving pictures and doing some thousands of feet of medical film personally we are honest enough to admit that the average audience carried away impressions of rather an indefinite character and far different than the operator meant to convey. The picture presented is referred to as wonderful, etc., but when the spectator is pinned down as to what he actually learned in a scientific way, he confesses, if he is honest, very little. This of course applies to the scientific and what is wrongly credited with being very technical. Again I repeat that the same picture after humanizing might not only be technical but instructive. Where steps in an operation are to be taken within the vision of the audience they must be taken rapidly and slowed down in projection, so that some mental impression of the procedure can be retained. We know that sixteen pictures are the actual number of changes in motion per second that are employed in motion photography. No one has yet stated the rapidity and retention of impressions of this character which are actually assimilated and retained. Only a fraction of what is seen is remembered, and it is surprising even to one constantly working in this field to realize how many new things are observed in each reshowing of the same picture. A picture can only be appreciated when seen a number of times and restudied. This may explain why so many in an audience are able to retain so little of the scientific and so much of the spectacular. If this observation is correct, we must take the people as we find them, and plan our work accordingly. The student in the medical school is wonderfully benefited by observing the sequence of procedure in operations. This applies to what can be visualized. The true value in technic can be gained in no place but the operating room, and then at the side of a teacher who impresses his various steps upon the student and lets each procedure sink in. What takes an hour in the operating room, may be crowded into ten or fifteen minutes in a reel-it is small wonder that confusion may result. Unless the operator stands beside his screen when the pictures are projected and explains the various steps in his operation, much may pass unnoticed or unappreciated. On the other hand, long titles are either trying on the eyes, or so long that an audience refuses to read them. . It is far easier to visualize general motion than to give in clear detail the work on an operative field. An audience tires of the concentration, and for this reason becomes fatigued more easily than where the motive is more apparent. On the other hand, where motion is of major significance and the idea to be presented is simplified, we find a most instructive field. Postoperative results, with renewed use of the part, the gaits of the ataxic, the various methods of medical diagnosis involving motion, etc.-these lend themselves to visualization. Moving pictures have come to stay. Let the medical profession line themselves on the side of progress, neither carried away by the possibilities of self-exploitation nor, on the other hand, losing the teaching possibilities by too much of the spectacular. Let us steer a middle WASSERMANN PARADOXUS D. M. Kaplan, in the New York Medical Journal, states that a weakly positive Wassermann reaction is of value only when the serum comes from a patient who has been treated for syphilis. In the absence of definite signs of lues in the history or in the physical examination, or in the presence of puzzling and undefinable phenomena, a weakly positive result is of no value whatsover. Not only are there positive reactions in nonleutic diseases, but also weakly positive reactions in people who complain of nothing and never had lues in any of its forms. In using two antigens one finds that the cholesterinized extract is usually the one that gives a more complete inhibition than the crude alsoholic nonreinforced product. It is by no means a rare occurrence to have complete hemolysis with the latter and equally strong inhibition with the former. A four plus result with a serum showing complete inhibition with both extracts becomes gradually less positive in the tubes containing the noncholesterinized antigen as a result of proper therapy. Only after more thorough and continuous treatment does the cholesterinized tube begin to show evidences of negativation and gradually become less intensely plus. Schematically one may picture the progress as follows: Cholesterinized Four plus Noncholesterinized Antigens Four plus Four plus Three plus Three plus Two plus Three plus One plus Two plus One plus One plus Minus The above scheme is somewhat arbitrary and tends to show that long before the reinforced extract gives a negative result, the noncholesterinized antigen has been negative on more than one trituration. In reviewing my serologic material at the Neurological Institute for the past three years, I found that certain patients presented a serologic behavior just the reverse of the one pictured above, i. e., their inhibition from the start was strongest, in fact repeatedly four plus in the noncholesterinized tubes and either weakly plus or entirely minus in the reinforced test. I recall with regret the time when I reported four plus on certain serums six or seven years ago when cholesterinized antigens were not yet in use. An instance of this kind on account of its importance I cannot forget. It concerned the son of a minister who was a patient of Dr. Charles L. Dana. There was not the slightest suggestion of lues, the patient suffering from epilepsy. I was not at that time in a position to account for the four plus result and only hoped to be able to explain it at some future date. Since then such results have been obtained on numerous occasions, all being patients in whom lues could be definitely excluded. However, when the cholesterinized antigens became an addition to the serologist's method, these serums behaved in the peculiar manner mentioned above. Upon a closer analysis from the clinical point of view a very interesting situation disclosed itself. This paradox Wassermann invariably came from patients who displayed one or more manifestations of motor unrest, such as spasms, tics, tetanoid movements, fainting spells, and convulsions. Many presented that type of epilepsy that still parades under the designation of "idiopathic." All of them showed no signs of lues in their physical analysis or in their history. A few cases were given the benefit of the doubt, but neither mercury nor salvarsan nor the combined treatment showed any improvement in these cases. The spinal fluids when analyzed never showed an abnormal condition. The connection between this motor unrest or spasmophile tendency and the positive results with noncholesterinized and negative with reinforced antigen is unexplainable, at least for the present. It must be borne in mind that not all cases showed this peculiarity and that many apparently similar cases resulted in a negative with both extracts. The Wassermann paradoxus should always be guarded against, as it may cause trouble when only non reinforced extracts are used. The situation has nothing to do with lues, but rather with a neural state that permits a deviation of the complement in the absence of cholesterin. A SANE AND PRACTICAL METHOD IN THE TREATMENT OF ACUTE GONORRHEA Henry J. Millstone, in the New York Medical Journal, advises that our great slogan in treatment of acute gonorrhea should be: Treat the urethra with as much precaution and respect as we do the mucous membrane of the conjunctiva. In this way we will fulfill every requirement necessary to control this infection. For years we have been using yellow oxide of mercury ointment in the treatment of all forms of conjunctivitis with brilliant results. Of all the preparations that I could possibly think of this preparation seems to fulfill all of the above requirements. Another great inhibiting factor in our treatment is the question of erections and nocturnal emissions. While our textbooks do not place very great stress upon it, I know of nothing that is so detrimental and annoying to the patient and nothing that does more damage. It is a known fact that during an erection intraurethral pressure is much greater than paraurethral pressure, therefore the pus in the urethra is pushed out into the surrounding tissue. The pain sometimes in an erection is excruciating, due to the tension of the inflamed tissue. This is the cause of the much dreaded chordee, which is simply a paraurethritis. For years textbooks have been recommending camphor monobromate to combat these conditions, but in my experience I find that this drug has a stimulating instead of a sedative action. When chordee already exists some men even go so far as to give morphine to prevent erections. Realizing the importance of keeping the penis absolutely flaccid for at least two weeks after the onset of the infection, I have had a special mechanical device made, which fits over the penis. As long as the penis is flaccid this device cannot be felt, but when an erection occurs it produces marked pain, hence the erection subsides. When erection occurs at night, it wakes the patient and prevents a nocturnal emission. This little instrument is the most practical way of handling this condition, and, since I have been making my patients wear them day and night for at least ten days after the onset, I have not had a single case of chordee and the comfort to the patient is gratifying. At the present time I have a series of twentytwo cases that I have treated with this idea in mind, and I may say with all sincerity that the results in practically every case are most astounding. To illustrate my point more clearly I shall give the history of a case with the method used. Case I.-Mr. M-, a bank clerk, came to me September 2, 1916, with a history of being exposed three days previous. There was no history of a previous infection. Upon examination the glans was found to be slightly edematous. The labia of the meatus were everted and markedly reddened. The entire shaft of the penis was tender to the slightest manipulation and the patient complained of frequent and painful mieturation. There exuded from the meatus a rather profuse greenish yellow pus, which upon microscopical examination revealed myriads of Gram negative intracellular diplococci and pus cells. Diagnosis Acute interior gonorrheal urethritis. Treatment: The patient was given all the instructions pertaining to cleanliness, diet, etc. He was instructed to report the next morning with his bladder full. The next morning at the office he was asked to void his urine, retaining some of it. Next two drams of a fifty per cent. solution of peroxide of hydrogen were gently introduced into the anterior urethra with a soft rubber ear and ulcer dropper. This was retained five minutes. The patient was again asked to void the balance of the urine. The peroxide is not used for its germicidal properties. When peroxide is introduced into the urethra ebullition takes place, and this mechanically balloons out the urethra and opens up the crypts and lacunæ. In this manner the pus and the organisms are dislodged into the lumen of the urethra and the rest of the urine washes it out. Two drams of a very warm saturated solution of boric acid were next introduced with the same precaution and also retained five minutes and expelled. The shaft of the penis was now milked to expel as much of the boric acid solution as possible and the meatus dried with a piece of gauze. Two drams of a one per cent. yellow oxide of mercury ointment were now introduced slowly. The penis was massaged so a to get the ointment well into all the crypts and lacunæ, and allowed to hang dependent in a clean gonorrheal bag. Do not place gauze and cotton over the meatus, as is so frequently done, as this interferes with the proper drainage of pus. Internally all that was given was one teaspoonful of sodium bicarbonate, t. i. d. The patient was given one of the rings which I have described and told to wear it for ten days. This treatment was given once daily for ten days. At the end of the third day all the ear marks of an acute gonorrhea had disappeared, nothing remaining except a serous discharge which was only noticed in the morning. By the end of the fifth day all signs of a discharge had ceased. All the other cases responded just as favorably as this case, and in no case did I have to treat the patient longer than fifteen days, most of them responding in from three to ten days. At the end of two weeks I obtained an ejaculated specimen from each patient and in no case was I able to find the gonoccocus. The advantages of this treatment are: 1. It prevents pushing the pus into the posterior urethra. 2. It prevents the patient from doing any damage to himself by self-medication. 3. It is an inexpensive method. 4. The treatment is simple and clean. 5. It prevents your prescription from going around the neighborhood. 6. It will settle the question of strictures. 7. You are using a remedy that you are familiar with and know its therapeutic value and not proprietary and patent remedies. 8. The ointment is very soothing and nonirritating. This, in my estimation, and I am sure that a fair trial will bear me out, is the most scientific and logical method in the treatment of acute gonorrhea, and more nearly approaches a specific than any other preparation I have tried. It fulfills all the conditions theoretically and is proving its value practically. Flavine and Brilliant Green as Antiseptics.— Browning, Gulbransen, Kenway and Thornton, in the British Medical Journal, have investigated the properties of a series of antiseptic substances, including phenol, mercuric chloride, iodine, the hypochlorites, chlorine water, malachite green, brilliant green, crystal violet, ethyl violet, and flavine. They state that an ideal antiseptic should have great potency against all organisms in the presence of protein; that it should have no harmful influence in phagocytosis; that it should be free from irritant or destructive action on the cells of the host; that it should be relatively nontoxic when absorbed; that it should stimulate the growth of connective tissue and epithelium. With two exceptions all of the substances studied failed in one or more of these respects-all but these two were reduced in effectiveness in the presence of proteins. The two exceptions were flavine and brilliant green, the latter retaining its activity in the presence of proteins, the former having increased activity in their presence. Brilliant green was found to be deficient only in not being destructive to several bacilli, although very highly so to cocci. Flavine was potent against both bacterial forms. Both flavine and brilliant green serum. produced marked acceleration of epithelial and connective tissue growth. Flavine was found to be 800 times as efficient as mercuric chloride against staphylococci in the presence of blood It was found also that it could be dissolved in solutions of sodium chloride containing up to five per cent. of the latter and hence could be used in conjunction with the hypertonic treatment. Both flavine and brilliant green were tried in a large number of unselected cases of wounds, either to control existing infection or to prevent the occurrence of infection. The results were strikingly favorable, and the average healing time was reduced to half the usual required by other methods of treatment. A one to 1,000 solution was usually used, both to wash the wound and as a wet dressing. NOTES BY EVENTS AND THINGS THE WAY AS SEEN BY THE EDITOR At the close (let us say) of Queen Anne's reign, says Thackeray in his Essays on Snobs, when I was a boy at a private and preparatory school for young gentlemen, I remember the wiseacre of a master ordering us all, one night, to march into a little garden at the back of the house, and thence to proceed one by one into a tool or hen-house, (I was but a tender little thing just put into short clothes, and can't exactly say whether the house was for tools or hens,) and in that house to put our hands into a sack which stood on a bench, a candle burning beside it. I put my hand into the sack. My hand came out quite black. I went and joined the other boys in the school-room; and all their hands were black too. By reason of my tender age (and there are some critics who, I hope, will be satisfied by my acknowledging that I am a hundred and fifty-six next birthday) I could not understand what was the meaning of this night excursion-this candle, this tool-house, this bag of soot. I think we little boys were taken out of our sleep to be brought to the ordeal. We came, then, and showed our little hands to the master; washed them or not-most probably, I should say, not-and so went bewildered back to bed. Something had been stolen in the school that day; and Mr. Wiseacre having read in a book of an ingenious method of finding out a thief by making him put his hand into a sack (which, if guilty, the rogue would shirk from doing), all we boys were subjected to the trial. Goodness knows what the lost object was, or who stole it. We all had black hands to show to the master. And the thief, whoever he was, was not found out that time. I wonder if the rascal is alive-an elderly scoundrel he must be by this time; and a hoary old hypocrite, to whom an old school fellow presents his kindest regards-parenthetically remarking what a dreadful place that private school. was; cold, chilblains, bad dinners, not enough victuals, and caning awful! Are you alive still? I say, you nameless villain, who escaped discovery on that day of crime? I hope you have escaped often since, old sinner. Ah, what a lucky thing it is, for you and me, my man, that we are not found out in all our peccadilloes; and that our backs can slip away from the master and the cane! Just consider what life would be, if every rogue was found out, and flogged coram populo! What a butchery, what an indecency, what an endless swishing of the rod! Don't cry out about my misanthropy. My good friend Mealymouth, I will trouble you to tell me, do you go to church? When there, do you say, or do you not, that you are a miserable sinner, and saying so, do you believe or disbelieve it? If you are a M. S., don't you deserve correction, and aren't you grateful if you are to be let off? I say again, what a blessed thing it is that we are not all found out! Just picture to yourself everybody who does wrong being found out, and punished accordingly. Fancy all the boys in all the school being whipped; and then the assistants, and then the head master (Doctor Bradford let us call him). Fancy the provost-marshal being tied up, having previously superintended the correction of the whole army. After the young gentlemen have had their turn for the faulty exercises, fancy Doctor Lincolnsinn being taken up for certain faults in his Essay and Review. After the clergyman has cried his peccavi, suppose we hoist up a bishop, and give him a couple of dozen! (I see my Lord Bishop of Double-Gloucester sitting in a very uneasy posture on his right reverend bench.) After we have cast off the bishop, what are we to say to the Minister who appointed him? My Lord Cinqwarden, it is painful to have to use personal correction to a boy of your age; but really Siste tandem, carnifex! The butchery is too horrible. The hand drops powerless, appalled at the quantity of birch which it must cut and brandish. I am glad we are not all found out, I say again; and protest, my dear brethren, against our having our deserts. To fancy all men found out and punished is bad enough; but imagine all women found out in the distinguished social circle in which you and I have the honor to move. Is it not a mercy that so many of these fair criminals remain unpunished and undiscovered? There is Mrs. Longbow, who |