bad. Portions of them remain undigested in the stomach for many hours.

Milk in adults is an uncertain article. It answers very well for some persons, not at all for others.

Meat is usually readily and well digested, but there are occasional exceptions to this rule.

Vegetables and fruits can be eaten, but the particular varieties must be selected experimentally for each patient.

I do not believe that any case of chronic gastritis is to be cured by diet alone. Even the exclusive milk diet, while it often relieves symptoms, is, as a rule, only temporary in its effect, so that the patient simply loses a certain amount of time by employing this instead of more efficacious plans of treatment. The advantageous use of drugs belongs to the earlier stages of chronic gastritis. At that time they often palliate symptoms and sometimes seem to cure the inflammation. In the later stages of the disease their use becomes more and more unavailing.

The Use of Local Applications made directly to the Mucous Membrane of the Stomach. This I regard as the most efficacious plan of treatment for those patients who are not able to leave home and seek a proper climate, but ask to be relieved without interruption to their ordinary pursuits. The local applications are readily made by the introduction of a soft rubber tube through the esophagus into the stomach. Liquid applications are the best. They should be made in such quantities as to come thoroughly into contact with the entire surface of the mucous membrane, although the pyloric end of the stomach is the region where the inflammation is principally situated. They should be made at a time long enough after eating for the stomach to be as nearly empty as possible.

For many cases, warm water alone in considerable quantities is the only local application needed. In some, however, there is an advantage in medicating the water and for this purpose I employ a variety of substances. The alkalies, the mineral acids, bismuth, carbolic acid, the salicylates, iodoform, belladonna, ipecac, gelsemium, may each one be employed according to the particular case.

For two or three months the patient has to be kept under observation and the applications to the stomach made by the physician. After this the patient is dismissed, but continues. the treatment himself, first every other day, then twice a week, then once a week, week, for several months. The regular relapses of the disease are managed in the same way, but are much more quickly relieved.

The committee on permanent organization reported a constitution and by-laws which after several amendments was adopted. The main provisions of the constitution are:

That the association has for its object the advancement of scientific and practical medicine. It shall be known as the Association of American Physicians, and shall hold its annual meeting in the month of June in the city of Washington, D. C.

That the proceedings shall consist of discussions on subjects of general interest in the departments of medicine and pathology, of original communications and of demonstrations of gross and microscopic preparations, of apparatus and of instruments.

That there shall be members and honorary members. The number of members shall be limited to one hundred. Physicians of sufficient eminence to merit the distinction may, to a number not exceeding twenty-five, be elected honorary members and as such shall be entitled to attend all meetings and take part in the proceedings, but not to vote upon business questions.

That nomination for membership shall be signed by two members, be referred to the censors and be acted upon at the succeeding meeting.

The following nominating committee was then appointed to report on Friday morning: Drs. James Tyson, A. Brayson Ball, George B. Shattuck, Frank Donaldson and Hosmer A. Johnson.

The first paper was entitled

TENDON-JERK AND MUSCLE-JERK IN DISEASE, ESPECIALLY WITH REFERENCE TO POSTERIOR

SCLEROSIS OF THE SPINal Cord.

BY S. WEIR MITCHELL, PHILADELPHIA. A tabular statement was then presented giving the results of observation in twentythree cases of locomotor ataxia. In this table the various symptoms and signs presented were represented by signs. In this way the history of each case could be seen at a glance.

In selecting a decisive symptom by which to arrange the cases into classes, station or the ability to stand, was selected. This can be accurately estimated by having the wall back of the patient ruled in inches. The examiner takes his place in front of the patient and directs the patient to keep his eye on a particular spot above the head of the obser ver. It is then noted how much he varies laterally with his eyes open. He is then turned so that the anterior posterior sway may be noted. The examination is then made while the patient has his eyes closed. Numerous examinations made by Dr. Guy Hins

dale show that the normal man does not sway over one-half inch laterally and not over threefourths of an inch in the anterior posterior direction. The normal man sways forward first, and first to the right. When the sway is more than three-fourths of an inch in the lateral direction or more than one inch in the antero-posterior direction, the case should be looked upon with suspicion as indicating that the general health is disturbed or that there is some disease interfering with the maintenance of the equilibrium.

In the cases examined the knee and ankle jerks and their reinforcement were absent at the time when the cases came under observation. The changes in the arm jerk seem to advance in the same way as the leg jerks, although they come on later. In the paralytic stage the muscle jerk is increased although the reinforcement is absent. In the first stage of locomotor ataxia, the tendon jerk is diminished or absent, while the reinforcement is fair. In the subsequent stages both the tendon jerk and its reinforcement are absent. The muscle jerk and its reinforcement continue normal through the first two stages. In the third stage, while the muscle jerk is normal, the reinforcement is absent. In the fourth stage the muscle jerk is increased while the reinforcement is absent. In the fifth stage, the muscle jerk is diminished and the reinforcement is absent. In the sixth stage, both the muscular jerk and the reinforcement are absent. The increase of the muscle jerk late in the disease may be due to some irritative changes in the muscle, but this has not been positively determined.

In a

In regard to associated movements. certain proportion of cases, if the patient is directed to shut his right hand, the left will also shut to a certain extent; and if the patient is sitting down the leg may be drawn up.

This condition has become more marked as the ataxic condition has increased.

Another symptom referred to and which was considered a new symptom, was prominence of the eye balls. While the condition is not as marked as in exophthalmic goitre, it is sufficiently distinct to be apparent if attention has been called to the matter.

The discussion was participated in by Dr. Seguin, Dr. James T. Putnam, and Dr. H. C.

Wood.

TYPHOID FEVER.

BY F. PEYRE PORCHER, M. D., CHARLESTON, S. C. The author described a method of treatment which he considered very satisfactory. As in all cases of high temperature there is costiveness, the result of the arrest of the in

Pulv. ipecac.,

M. et ft. pulv. No. 1.

Sig. One powder every four or five hours. as required.

things are to be considered, the necessity for
In the treatment of typhoid fever three
maintaining the strength of the patient, the
support
lants, and the morbid effect of high tempera-
of the system by the use of stimu-
ture. Special attention was directed to the
latter element of the treatment. In reducing
the use of ice-cold water which was applied
the temperature, the speaker had resorted to
to the head, hands and arms by the use of
towels wrung out of the water and reapplied
as frequently as necessary. The applications
are continued for ten to fifteen minutes until
the heat of the skin is reduced. The use of
baths was considered objectionable on ac-
count of the difficulty of their application and
on account of the prejudice against them. He
prescribes for internal use a fever mixture
prepared somewhat as follows:
R Potassii acetatis,

Liquor. ammonii acetatis,
Spr. ætheris nitrosi,
Tinct. aconiti,

Aquæ, ad,

i

3s8

Ziv

Sig. A dessertspoonful in a little water every two hours, so long as the fever con

tinues.

the above preparation. It may also be emMorphia or the bromides may be added to ployed in other fevers.

em

Hot pediluvia may also be employed. In malarial cases, quinia and arsenic are ployed. Later the use of the mineral acids is added. With reference to the use of stimulants, these may be continued as long as the tongue is dry. Oil of turpentine is often called for on account of tympanitic distension of the abdomen. It is also of

value as an astringent and as a general stimulant. The speaker had treated thirty cases in private practice in this manner, of which number three died. In these cases there were causes sufficient to explain the fatal termination.

DISCUSSION.

DR. JAMES TYSON, Philadelphia. Recently in a case under my observation, I, in order

to reduce the temperature, wrapped the patient in a sheet which was kept constantly wet with ice-water. This was entirely suc cessful. In this case both antipyrine and thalline were employed, but, although they promptly reduced the temperature, it soon returned to its original position. When it is necessary to keep the temperature continuously reduced, some modification of the cold pack is, I think, the best method.

DR. WILLIAM H. DRAPER, New York. There is, perhaps, nothing more fallacious than statistics in typhoid fever. Cases of fever not truly typhoid are confound ed with specific typhoid fever. We have all seen cases in which there was a continued fever, but in which the temperature did not run the typical course. I think that in such cases we have no evidence that they are cases of typhoid fever.

Experience shows that the value of antipy retic treatment in typhoid fever may be readily overestimated. I think that in the majority of cases the value of antipyretics is not so much in reducing the mortality as in affording comfort to the patient.

DR. WILLIAM PEPPER, Philadelphia. We have hospital statistics showing the normal course of typhoid fever, which would make us slow to accept a mortality of fifteen or even ten per cent as evidence of much suc

cess.

It is evident that in typhoid fever we have different sorts of fevers, and a remedy applicable to one set of cases may not be to another. An excellent rate of mortality may, I think, be secured by absolute rest from the first moment of suspicion, and a rigid diet of milk or milk diluted. In addition, I believe that the abstraction of heat by the use of cold water is of great value. I believe that some remedy directed to the constant and important lesion of typhoid fever aids in reducing the temperature. I do not know that we have positive knowledge as to the best drug for this purpose. My own preference is for the salts of silver. If the case comes under observation early, is put at absolute diet, and receives proper treatment, I think the mortality should not exceed five or six per cent. In private practice, I believe it can be kept down to this.

THURSDAY AFTERNOON SESSION. Discussion of the question:

"Does the present state of knowledge justify a Clinical and Pathological Correlation of Rheumatism, Gout, Diabetes, and Chronic Bright's Disease?"

Referee, DR. JAMES TYSON, Philadelphia. Co-referee, DR. WILLIAM H, DRAPER, New

York.

DR. TYSON, the referee, began by defining the diseases included in the subject. The usual definitions of rheumatism and gout, as general diseases with local expressions were given. Diabetes was subdivided into two varieties, the milder and more severe form. The former consists, essentially, in a defect in that particular metabolic office of the liver by which glucose is converted into glycogen. It is due to over-stimulation of the liver cells by the excess of absorbed glucose, arising from the habitual over-use of saccharine and starchy food. The more severe form of diabetes may be termed neurogenous and is caused by some direct or reflex influence on the vaso-motor center, whence arises a hyperemia and accelerated circulation through the liver, as the result of which the glucose absorbed during intestinal digestion is carried too rapidly through the liver to permit its conversion into glycogen. To this is added, in advanced stages, glycogen resulting from the splitting up of the products of digestion of nitrogenous foods.

Taking up the discussion, first as to rheumatism and gout, the referee called attention first to the difference in the morbid anatomy of the two diseases. In the absence of anything specific or peculiar in the change in the joints in rheumatism, while in gout there is the peculiar deposit of sodium urate in the joints or their vicinity. The composition of the blood is defi nitely altered in gout by the almost constant presence of an excess of uric acid in combination with sodium, whereas no change of corresponding importance is found in the blood of rheumatism. Heredity plays a much more important role in gout than in rheumatism, reaching in the former, according to various observers, fifty to one hundred per cent., while in rheumatism the maximum claimed is thirty-four per cent. The early age at which rheumatism presents itself, as compared with gout, implies a difference in the etiology, as does also the absence of renal and the presence of cardiac complications. Alcoholic liquors and overindulgence of food have no influence in the causation of articular rheumatism. In gout they are all powerful.

The exciting cause of rheumatism is always cold, dampness, or both. The cause of the explosion or the acute attack of gout, is the cause of the disease itself, and is due either to the over-accumulation of uric acid in the blood, whether as the result of increased formation or defective elimination, or to diminished of resistance of the organ power ism through some accidental cause, atmos pheric or physical.

Moreover, except in the case of salcyilic acid, which is admitted by all to be useful in both affections, Dr. Tyson thought that the treatment required by the two diseases was different. The treatment of gout is eliminative, that of rheumatism is restorative. It is true salicyllic acid is efficient in both diseases, but this is not sufficient that they are the result of the same cause, so long as that cause is so easily demonstrated in one and not in the other. Nor is the case strengthened by the theoretical reasoning which so well explains the action of salcyilic acid, that it prevents the formation of uric acid in the blood by seizing upon the glycocine out of which uric acid is formed.

The relation of gout to that form of chronic renal disease known as chronic interstitial nephritis is a true correlation, since there is every reason to believe that the cause of gout is one of the causes of this form of chronic renal disease so common in gout, and the evidence of renal disease is often found long before the gout manifests itself.

To estimate the relation between gout and diabetes, it is necessary to remember that there are the two forms referred to; with neither of them is there any pathological relation. Between gout and the first or mild form of diabetes there is a clinical correla tion, although many of the facts on which it has been founded, the referee believed to be erroneous. Thus, although uric acid sediments are quite common in diabetes, yet careful quantitative analysis shows no increase in the amount of uric acid excreted. The uric acid sediments must, therefore; be the result of the excessive acidity so characteristic of diabetic urines, due to the fermentative processes.

Again, it is said the lithemic urines often contain sugar. This, he was confident, was much rarer than is commonly supposed, because of the fact that uric acid reduces the salts of copper, and this reaction is mistaken for that of sugar. He thought that the inability of gouty persons to digest saccharine and starchy elements of food should not be regarded as a proof of clinical correlation, because it simply indicates a feeble converting power of the intestinal digestive fluids over the carbohydrates. In diabetes there is no defect of this kind. The carbo-hydrates are converted into glucose with facility. The trouble is with the liver, which is not able to reconvert the glucose into glycogen.

Between gout and the more severe form of diabetes, which is the result of discase at a point distant from the liver, there is no correlation either clinical or pathological.

Between diabetes and Bright's disease there is a relation of this kind. The effect of the circulation through the kidneys, surcharged with sugar alone or with sugar, acetone and diacetic acid, is to irritate the renal cells and produce a degree of chronic parenchymatous nephritis instead of the interstitial nephritis, which is so closely correlated with gout. From recent observations, there is reason to believe that these changes take place in the kidney much earlier than used to be supposed, and that albuminuria appears correspondingly early, either coincidently or in alternation with glycosuria. The difference between the relation of gout to Bright's disease and of the more severe or neurogenous diabetes, is, that in the former that which causes the gout causes the Bright's disease, so that there is a true correlation; whereas in neurogenous diabetes, it is a result of the diabetes which causes the renal complication. As to diabetes and rheumatism, the idea that these two diseases are closely correlated, has apparently received substantial support from the results of treatment of the two diseases by salicylic acid. Oscasional reports as to the efficiency of salicylic acid in diabetes, have acquired additional impulse from views which have recently been promulgated by Latham, who concludes on clinical grounds that there are two forms of diabetes. One due to neurotic disturbances of the function of the liver and the other due to neurotic disturbances of the functions of muscle. the result of the latter, glucose is formed in the muscles and passes thence into the circulation. This latter is so closely related to rheumatism that one degree of oxidation developes the materies morbi of rheumatism, and another developes glucose. Having shown also by the same reasoning that the administration of salicylic acid arrests the formation of uric acid, lactic acid and glucose, he explains the usefulness of salicylic acid in some forms of diabetes, and says that in doses of from ten to twenty grains, three times a day, he has seen it produce marked improvement. More recently, Holden reports the successful treatment of six cases of diabetes with salicylic acid.

As

The referee whose experience with salicylic acid in the treatment of diabetes had not heretofore furnished satisfactory results, had not yet had the opportunity of applying this more recent principle, that it is in the cases with rheumatic pains that it is especially serviceable. He held that until more cases were collected in which this principle of treatment was applied, the question was not ripe for decision. In a single case which had

come under his observation, in which it was claimed that salicylic acid had been very useful, the sugar had been found increased rather that diminished.

DR. Wм. H. DRAPER the co-referee said: It is fair to presume that this question would not have been propounded if clinical experience did not suggest it. It certainly is not yet justified by the present state of knowledge in pathology. Although the question is premature from a pathological point of view, it can hardly be regarded as without interest and possibly importance, from a clinical standpoint. It is from this latter aspect that my remarks shall be made.

By gout is meant, I take it for granted, not simply the arthritic malady, but a diathesis which manifests itself through more or less well defined derangements of nutrition, which give rise to a variety of secondary cerebrospinal irritation and provoke definite structural changes in the blood vessels, in the connective tissue of the parenchymatous organs and in the nervous system.

By diabetes we are to understand I suppose the more common and lesser form of that dis

ease.

Rheumatism is so vague in its ordinary application that it is not easy to comprehend exactly what is meant in this question. It is presumed that it covers acute articular rheumatism and the subacute forms in which the differential diagnosis from subacute gout is so difficult.

The form of Bright's disease is probably the form of chronic diffuse nephritis which is characterized by extreme sclerotic changes in the connective tissues of the kidneys and in the arteries and by cardiac hypertrophy.

I think that the experience of most clinical observers will justify the statement that gout, rheumatism, diabetes and chronic Bright's disease are frequently associated, sometimes in the same individual history, more frequently in the histories of families. The association of gout and even chronic rheumatism with chronic Bright's disease is very common in the individual, while the association of gout with diabetes, or of diabetes with granular kidney, is not common. Chronic rheumatism may exist without even being complicated with gout or diabetes or chronic nephritis, but in families where the association of morbid phenomena can be traced, I think that it will be acknowledged that these diseases are frequently found in more or less marked alliance.

Granting this association, are their any facts to show their correlation? Are they reciprocal, interchangable affections, transmu

tations of the same morbid process, and therefore recognizing a common determining cause as yet unknown ?

The first fact that suggests the idea that they are cognate forms is that of heredity. First as to gout and diabetes. Glycosuria often recognizes a gouty ancestry. The term glycosuria being used to express the lighter form of the disease. In many cases the grave form of diabetes is not traceable to a gouty origin. The speaker had seen many cases leading him to believe that excluding the cases of diabetes of nervous origin, careful investigation of the family history would reveal the presence of gout in the majority of cases. Second, concerning gout and rheumatism, the fact of heredity as establishing a connecting link is not so evident, but it has been pointed out that articular rheumatism frequently occurs in the children of gouty parents. The influence of heredity in determining the association of the subacute form of rheumatism and gout, can not be positively decided.

Third, as to the frequent manifestation of heredity in the history of gout and interstitial nephritis, I think that there can be no question. This form of Bright's disease not only occurs as a complication of inherited articular gout, but is often observed in the members of gouty families who have themselves never exhibited any articular lesions. This is especially seen in the female line.

I wish next to call attention to the association with these diseases of certain common derangements of nutrition. While it can not be claimed that organic chemistry has as yet done more than formulate the general principles that gout and diabetes are associated with the signs of incomplete metamorphosis of the food elements, it is daily making progress in solving the complex processes by which each atom of carbonaceous and nitrogeneous food is finally resolved into carbonic acid and urea. In these two diseases there is a diminished capacity for converting the carbohydrates. The occurrence of sugar in the urine of gouty persons is not infrequent, and of lithic acid deposits in the urine of diabetics is not infrequent.

Gout, diabetes and rheumatism in their treatment by medicines, exhibit reciprocal relations. In these various affections the alkaline treatment is used with benefit. It is admitted that the value of alkaline treatment in acute rheumatism is not sufficiently well established to justify the proposition that the disease is one that ground a correlation of gout. The value of salicyl compounds in the treatment of gout, diabetes