cases to have occurred during sleep. Where although the cerebral arteries are contracted, the pressure within is increased in consequence of the influence of gravitation from the position of head in reference to the rest of the body while we are asleep. Premonitory symptoms are rare. As a rule, the patient is seized while in full health. In the cases that I have seen, the feces have not been injected but have been of ashengray hue.

The condition of the pupils varies a good deal, depending upon seat of lesion in my opinion. Swanzy and Berthold claim that they are at first contracted and that this is one of the diagnostic points between hemorrhage and embolism, where, as they say, the pupils remain unaltered, but I do not believe that these opinions are correct. The respiration is generally accompanied by stertor. The pulse is full, slow, and of increased tension. Temperature is usually normal. When it is subnormal the prognosis is grave. I do not agree with Dr. Tompkins when he says that it is difficult to tell at first whether hemiplegia exists or not.

A valuable indication whether the hemorrhage is associated with hemiplegia may be found in the difference of the tonus of the muscles of the two sides. If the arm or leg on the affected side is lifted, it drops dead, whereas on the other side they drop more slowly. I am treating a case now where the hemorrhage occurred about two weeks ago near the internal capsule, producing a left hemiplegia. All the cases that I have seen in my practice have been those of left hemiplegia and in most of these, strange to relate, the speech centers have been affected also. The return of motion in this case has been slow. I am inclined to think that there will be some permanent palsy remaining which is generally the case where the power of movement is not recovered within a month after hemorrhage.

Little can be done to prevent cerebral hemorrhage when miliary aneurisms and the degenerative changes incidental to old age are once formed. Venesection, which was followed for so long a time, is now very rarely used because we do not

see our patients, as a rule, until the damage is done, but it is admitted by all authorities that no other agent reduces so quickly the tension of the blood. Another reason that venesection has so justly fallen into disrepute is that it is not always so easy when the patients are comatose to diagnose cerebral hemorrhage from embolism and thrombosis, in which cases bleeding would do much harm. Compression of the common carotid in the neck has been advocated by Spencer and Horsley for arresting bleeding from a branch of the middle cerebral artery. An important element in treatment is free purgation and we have a much more powerful and effective remedy in our hands now in magnesium sulphate, given in small doses, hypodermatically, than we had formerly in croton oil and calomel. In the case that I am treating now, one grain of sulphate of magnesium caused a free evacuation within an hour after administering it. We still use the old form of treatment of applying ice to the head where there is no collapse, and mustard application to the extremities, but most frequently all our endeavors are in vain and we realize that "all of the science of medicine seems but a vain groping in the dark, a blind and futile struggle with some relentless power which takes no account of human weakness and of human endeavor."

Dr. Bishop, a visitor, being invited to speak on the subject, said that as he had not heard Dr. Tompkins' paper he was unable to discuss it thoroughly, but from the description of the specimen cases he would say that he thought it probable in one of the cases that the clot might have been found under the cortex in the internal capsule. Syphilis is often a prominent factor in the causation of cerebral hemorrhage.

Dr. Glazebrook said that in relation to the fourth case cited by Dr. Tompkins he had recently made an autopsy on the body of policeman Kirby and thought it almost a similar one.

Death was very sudden, and when the skull was opened a large clot about three by three inches in size was found anterior to the right middle cerebral

artery. Further search for additional hemorrhage revealed nothing. Marked hypertrophy of the left ventricle was found. Thinned walls of blood vessels, hypertrophy of the left ventricle of the heart and some undue pressure seemed sufficient cause for cerebral hemorrhage.

The circle of Willis, or some adjacent blood vessels, usually on the left side, was the most common seat of the cases that he has seen. Most of the cases showed marked hemorrhage. In regard to traumatic hemorrhage, in all five cases of fractured skull that he has seen, the hemorrhage was not at the seat of injury, but on the opposite side; this fact he considered very important.

Dr. Van Rensselaer asked how Dr. Glazebrook accounted for this fact.

Dr. Mackall inquired if convulsions were present in the fourth case. Answer, Yes.

Dr. Snyder said that his experience had been that it was very difficult to diagnose. He remembers one case of cerebral hemorrhage which he watched closely, and observed marked symptoms indicating the parts of the brain affected. When he made the autopsy it developed that the case was one of abscess of the brain.

Dr. Glazebrook cited a case of suicide of a policeman. He had fired a bullet through the right parietal bone; on the opposite side was found a large hemorrhage and laceration of the dura mater and brain. The hemorrhage was about the size of two silver dollars.

Dr. Tompkins said that the case of fissure of the skull revealed a hemorrhage about the size of an orange on the right side, and was traumatic. Differential diagnosis between embolism and hemorrhage is the most important point. It takes a person of some expertness to discover an embolism. The hypodermatic injection of magnesia sulph. has not been successful in his hands.

Dr. Bowen presented the following pathological specimen. A young woman aged 26 years, three years married, never pregnant. Pain in a sitting position feeling like she was sitting on a ball, and she could not sit in one place more

THE ANASTOMOSIS BUTTON. Dr. Murphy of Chicago (Lancet) gave a demonstration on the dead body of the method of using the button devised by him. He commenced by saying that seven points required attention in attempting to obtain union between two pieces of bowel. They are: 1. Coaptation of surfaces, and the union should be between similar tissues — that is, the muscular coat should join the muscular coat, and the mucous membrane of one portion should be in contact with the mucous membrane of the other. 2. Adhesions should form immediately. 3. Sufficient caliber should be left at the point of union. 4. Permanent organized adhesions should result. 5. The line of union must not contract to any great extent. 6. The process should be aseptic. 7. The method employed should take the least possible time. He further pointed out that two sets of arteries supply the bowel- firstly the branches of the mesenteric arteries; and secondly the "parallel artery," which runs along the mesenteric border of the bowel. Of these two sets the parallel artery is the more important for the life of the bowel, for the mesenteric branches may be tied for a length of bowel equal to seven inches without any sloughing resulting, while the parallel vessel cannot be tied for more than half an inch without causing sloughing. Hence it is necessary in dividing the bowel to remove less of the mesenteric border than of the convex side. In taking the running stitch round the bowel it is important to make an overstitch at the mesenteric border in order to secure the parallel artery. The method was dem

LEGAL CONTROL OF SYPHILIS.-The time has certainly come, says Dr. Bulkley, when the dangers of syphilis, and especially the dangers to innocent persons, should be fully recognized. It is too late in the history of science and of humanity to stigmatize the disease as "venereal," and on that account to withhold scientific protection from thousands of innocent sufferers. Among babies, nursing women, persons infected in dental or surgical operations, and in dozens of other manners, syphilis can no more be described as a 66 venereal "

affection than any other contagious disease. The time has come to place it under the control of the proper health officers, and make it quite as criminal to transmit syphilis wittingly as it is to communicate smallpox, scarlatina or diph

theria.

RELICS OF EVOLUTION.-The coccyx is one of the vestiges of our animal ancestors, says the Scientific American, and presents an example, perhaps, of a reversion to the older type. We are familiar with the caudal projection of the human fetus that is like that of the animal, and we see in the dissecting room, at times, the vestiges of the tail muscles inserted into the coccyx. The plica semi-lunaris is a vestige of the nictitating membrane found in certain birds; there is the pointed ear, or the turneddown tip of the ear, of many men; the atrophied muscles, such as those that move the ear, well developed in certain people, or that shift the scalp, resembling the action of the horse in ridding himself of flies; the supra-condyloid foramen of the humerus; the vermiform appendix; the location and direction of the hair on the trunk and limbs; the dwindling wisdom teeth; the feet of the fetus, strongly inwards, as in apes, and persisting in the early months of life, together with great mobility and a distinct projection of the great toe, at an

angle from the other side of the foot; and the remarkable grasping power of the hand at birth and for a few weeks thereafter, that permits young babies to suspend the whole weight on a cane for a period varying from one-half to two minutes.

TUBERCULOSIS IN COLORADO.-Henry Sewall, Ph. D., M. D., Secretary of the State Board of Health, gives in the Colorado Climatologist for August the results obtained on the above subject from 400 circulars addressed to the physicians of that State. There is a prevailing idea, he says, even among the medical profession, that cases of consumption contracted in Colorado, either in city or country, form rare exceptions and almost take rank as pathological curiosities. The following statement will show that wherever statistics have been presented, having the ear-marks of careful investigation, there we usually find evidence of a sensible proportion of phthisis of home production, contracted, if you please, from imported cases but still developed here. In Denver, where the statistical information is most full and accurate, the facts show that consumption contracted in Colorado, and particularly in the city of Denver, already forms a very important factor in the death roll; indeed, the available statistics probably far undervalue the proportion of phthisis having its origin in our midst. 39 replies were received, 6 being from Denver physicians. The paucity of official records in the State is pointed out; those from Denver show that in the two years, 1893 and 1894, there were 3404 deaths from all causes; 812 of these were from tuberculosis, and of these 539 are stated not to have been contracted in Colorado and 100 to have been contracted in the State, the place of origin of the remainder not being reported. The number of deaths from consumption contracted in Colorado forms 0.37 per 1000 per annum of the population; 2.9 per cent. of the total number of deaths; 12.0 per cent. of all deaths from tuberculosis. Average annual death rate per 1000 from all causes, 12.89. The report

lays stress upon the communicability of the disease and upon the fact that the germ from which the indigenous cases was derived must have been imported, and points out "that only a vigorous crusade of prophylaxis will be sufficient to ward off the plague that has appeared upon the horizon."

THE TREATMENT OF DIABETES MELLITUS. — Robin (British Medical Journal) describes in detail the medical treatment -"alternating treatment "— which he prescribes in diabetes. He believes that in this disease there is an increased activity of the chemical changes of general nutrition, and of the hepatic cells in particular, which is the result of increased activity of the nervous system. Hence he recommends drugs which diminish the activity of these general changes by acting primarily on the nervous system. The treatment is divided into three stages: 1. For four days a powder, containing about fifteen grains of antipyrin and eight grains of sodium bicarbonate, is given twice a day. In addition cod liver oil is taken twice a day with the meals, and Seignette salt as a morning purgative. 2. At the end of four or five days the antipyrin is discontinued, and sulphate of quinine prescribed about six grains in a cachet at the midday meal. This is taken for six days, then discontinued for four days, and afterwards taken again for six days. Before the morning and evening meals a cachet is recommended containing arseniate of soda, carbonate of lithium, and codeia. 3. After fifteen days these drugs are discontinued, and the author prescribes, for ten days, a pill containing opium, belladonna, and valerian. The cod liver oil is discontinued, and the patient is allowed to drink a weak solution of bicarbonate of soda (1 in 125). In the case of nervous women, or if there should be intolerance of the opium and belladonna pills, fifteen grains of potassium bromide are given two or three times a day for eight days. In addition to the medical treatment the diet is regulated. On account of the loss of inorganic salts in diabetes

(demineralization) the auther recommends the food to be well salted; to supply potassium salts he advises green vegetables, especially cabbage and endive, and also a weak solution of potassium tartrate to dilute the wine taken at meals; and to counteract the loss of phosphates of magnesium and calcium. he prescribes glycero-phosphates of lime and magnesia. He also recommends bouillon on account of the inorganic salts which it contains. If sugar is still present in the urine after the third stage of the medical treatment above mentioned the course is recommenced. After a second course, whether sugar has disappeared or not, the drugs are discontinued for one month. Robin has treated by this alternating method 100 cases of diabetes, in each of which the daily quantity of sugar excreted was 100 grammes or more. In 24 of these recovery has occurred; in 25 recovery is still doubtful; in 33 there has been considerable and permanent improvement; in 18 the results have been negative.

NECESSITY OF FREQUENT VISITS.The Supreme Court of California (Todd vs. Myers, 40 Cal., 355), says the Sanitarian, in an action brought by a physician for professional services-the defense being that the visits were too frequent and not necessary-rules that: "The defendant having admitted the employment of the plaintiff as a physician to treat his wife and children, the plaintiff was the proper judge of the necessity of frequent visits, and in the absence of proof to the contrary the court will presume that all the professional visits made were deemed necessary and were properly made." It would be a dangerous doctrine for the sick to require a physician to be able to prove the necessity of each visit before he can recover for services. This is necessarily a matter of judgment, and one concerning which no one save the attending physician can decide. It depends not only upon the condition of the patient, but in some degree upon the course of treatment adopted.

MARYLAND

PUBLISHED WEEKLY.

TERMS OF SUBSCRIPTION, $3.00 a year, payable in advance, including postage for the United States, Canada and Mexico. Subscriptions may begin with any date.

DATE OF PAYMENT.-The date following the subscriber's name on the label shows the time to which payment has been made. Subscribers are earnestly requested to avoid arrearages. CHANGES OF ADDRESS.-When a change of address is ordered, both the old and new address must be given. Notice should be sent a week in advance of the change desired.

TO CORRESPONDENTS.-Original articles are solicited from members of the profession throughout the world. Reprints will be furnished in payment of accepted articles if the author's wish is so stated at the time.

CORRESPONDENCE upon subjects of general or special interest, prompt intelligence of local mat ters of interest to the profession, items of news, etc., are respectfully solicited. Marked copies of other publications sent us should bear the notice "marked copy" on wrapper.

Address: MARYLAND MEDICAL JOURNAL, 209 Park Ave., Baltimore, Md.

WASHINGTON OFFICE:

Room 22 Washington Loan and Trust Co. Building

BALTIMORE, SEPTEMBER 14, 1895.

THE inauguration of the four-year course, which it was fondly thought was already un fait accompli, has met

A Hitch in the Advance. with

a

unex

most pected setback. A defect in the wording of the rule enforcing the additional year has been quickly recognized by cunning Deans lying in wait for their foes and like Shylock, these gentlemen insist upon their rights to the full measure of the pound of flesh. But really we are not going to pick a quarrel with these gentlemen for so small a matter. A day or a month or even a year is no such great matter that we need work ourselves into a frenzy over it as some medical gentlemen seem disposed to do. We are not quite sure that an earthquake is going to destroy the world in the next twelvemonth and thus render the anticipated enjoyment of the advantages of the four-year course impossible. If we could foresee such a calamity we might indeed desire to make all possible haste, but we try to possess our souls in peace and be thankful for what has

Laying aside levity, there is no doubt that by a sort of pretty general consensus, it has been determined to postpone the four-year course until 1896. Catalogue after catalogue has come to us announcing the continuance of the three-year course for 1895 and 1896. Among colleges that have taken this decision are Bellevue, the University of Richmond, the Baltimore Medical and, we understand, all the St. Louis colleges. In view of this, and in justice to all, would it not be better for those colleges that have already announced a four-year course for 1895 and 1896 to reverse their action? Is it possible to obtain an expression of opinion on the subject from the American Medical College Association? Could not the Judicial Council of that Association assume authority to take this action? We have been informed that some of the fouryear schools are getting around the difficulty by matriculating students for a three-year course at any time prior to October 1, 1895.

Garbage Cremation.

THE difficulty of disposing of the accumulating garbage increases with the growth of cities. It becomes therefore a serious question how best to get rid of those rejected remnants of our food supplies and undoubted causes of sickness and death. The experience of Atlantic City upon this question is the more valuable and interesting because so unique. The recent phenomenal growth of this great summer resort has made the question there one of "burning "interest. In seeking for its solution many places were visited by the Board of Health and many processes and apparatus were inspected. The result was a unanimous decision in favor of cremation as being the most economical, sanitary, free from objectionable odors and easily managed method.

The "M. V. B. Smith" crematory, previously operated with natural gas at Muncie, Ind., was selected and modified so that it could be worked by ordinary gas. A description is given of this apparatus in the "Eighteenth Report of the Board of Health of New Jersey." So satisfactory did the first prove, that a second of nearly double the capacity, viz., 80 tons per diem, was erected