In the same cities there exists a patrol ambulance system in which the patrol wagons are equipped for ambulance use and are either the only ambulances or are run in conjunction with the ambulances owned by the various hospitals. In Boston the Police Department operates 10 regular ambulances in addition to patrol ambulances.

In most cities where the hospitals maintain ambulances they are not the only ones. Usually the police ambulances are in

requisition.

In no other city do the undertakers alone conduct the ambulance system. In this Cleveland has a unique system.

In very few cities is there an ordinance governing the ambulance system except to give the vehicles right of way and the privilege of unlimited speed. The service is usually operated by the police department, and this possibly because this department has a complete system of signals, a central bureau to which all calls can be sent, and an organized force of trained men.

In some cities, notably Cincinnati and Boston where they have a patrol ambulance system, a wagon responds to every fire call. In New York the ambulances receive all fire calls and a wagon responds at the third call.

With these facts and with the information and suggestions solicited from various sources, especially from the ambulance men themselves, the following possible plan suggests itself by which the services could be substantially and quite easily improved; it is one by which the present operators of ambulances would have proper recognition for their past good work and by which a little change would effect great improvement. The first plan suggested for the improvement of the present ambulance system was approved by the Legislative Committee and the Council of the Academy of Medicine, and the Legislative Committee was instructed to present the same to the City Council for possible adoption and enforcement.

1. Each ambulance operator should be licensed and before securing the license the establishment must be proved fully equipped with all the necessities for the proper conduct of its work.

2. The ambulance driver or attendant should be required to prove to the Board of Health that he has a sufficient knowledge of the principles of first aid to the injured.

3. All ambulance calls should be sent to the Police Central Exchange. The attendant here should despatch that ambulance

nearest the scene of accident, and in case that one is not available; the next nearest one should be sent.

4. Each ambulance should be assigned a certain territory. 5. The patient should positively be conveyed to the nearest hospital, except when he expresses a desire to be taken elsewhere.

6. The City Hospital should be opened to all classes of injured and this fact should be made known, and its ambulance should be required to respond to emergency calls.

By this simple plan the ambulance service will be under systematic control. The drivers or attendants will have to show competency. The wagons will be properly equipped. The public will know where to call. It will place the nearest ambulance on the scene in the shortest possible time. It will avoid more than one wagon making the same run. It will prevent the possible collision of drivers. It will assure the injured that they will be conveyed to the nearest hospital, and if the operator knows something of the nature of the accident, he can inform the hospital and they can be in readiness for the injured. To this plan very few, if any, valid objections can be raised, except that the department may be accused of showing favoritism, when two or more ambulances are in the same district.

To the foregoing could be added the police patrol wagon service. In many of the large cities the patrol wagons are equipped for ambulance service. Our present patrol wagons could easily be transformed into combination wagons. There are policemen who readily could acquire considerable degree of proficiency. There are in Cleveland 12 patrol stations some of which are situated in a district where there is at present need of an ambulance service. At the present time the untrained patrol wagon officers take the disabled to the patrol station and if in their wisdom it is deemed necessary, they then call an ambulance to carry the subject of their mercy to a hospital. The patrol ambulance wagon could be required to respond to every fire call, thus first rendering police service and secondly giving to the fireman a confidence similar to that which a soldier feels on a field of battle-that in case of injury he will be promptly cared for by the hospital corps.

To this latter plan some objections can be raised. It requires money to equip the wagons. The patrolmen might find this work. not to their liking. At the present time many patrolmen have been given this assignment because they are not physically able to perform the regular beat service, or for other considerations.

Then, too, it may be objected that by this arrangement the wagon might be called out at times when needed for police service.

The ideal ambulance service is that which is owned, equipped and maintained by the hospitals and manned by hospital men trained in the handling of the sick and injured, who are privileged to exercise their judgment in all that pertains to the service. However, no such scheme for such an ideal service is now proposed, for we must not waste our time in the contemplation of the now unattainable. But in this age of rapid transit, swiftly-moving street cars, numerous railroad crossings at grade, speeding automobiles, electrically-charged overhead wires, thousands of factories vibrating under the power of dangerous engines, these and countless other factors having great possibilities for injury. to men, demand some effort to reform this city's atrocious and haphazard way of mishandling the accidentally injured.

2316 E. 55th Street.

Achondroplasia

By S. L. BERNSTEIN, M. D., Cleveland, O.

The rarity of achondroplasia justifies the reporting of every case that comes under observation. Though of an ancient origin, for the gods of Ptah and Bes were undoubtedly examples of it, it has not been commonly recognized as a special form of antenatal bone disease. That it has been mistaken for simple rickets or cretinism may explain the unusually few cases recorded. Already in 1856 Virchow had his attention occupied by certain fetuses. with unusually large heads and short limbs. In 1860 Müller1 recognized it as a definite pathologic entity, also that the disease. is one of primordial bone cartilage and that the inhibition of the growth of the long bones is due to a disturbance of the normal. arrangement in rows of the proliferating cartilage cells. Winkler in 1871 distinguished the condition from ordinary rickets and suggested the name "rachitis micromelia." Urtel2 in 1873 gave an account of the macroscopic and microscopic appearances presented by a still-born child which corresponded in all details to Müller's case presented some years before. Earlier observers noted cases as congenital rickets but which, in the light of more. recent investigations, were examples of achondroplasia.

The name "achondroplasia" was suggested by Parrot in

Read before the Clinical and Pathological Section of the Academy of Medicine of Cleveland, December 6, 1907

1878 and is commonly used though the more accurately descriptive title "chondrodystrophia fetalis hyperplastica," given it by Kaufmann3 at a later date is more correct. The term "achondroplasia" implies no growth of cartilage cells at all, this is obviously a mistake, as there is plenty of cartilaginous activity but not in the direction of increasing the length of the limb bones. Many other names have been given to this disease by various writers, based upon the experience gained by examining one case or one specimen but they have not succeeded in clearing up, to any appreciable extent, the obscurity that surrounds the whole subject. Consequently we have such other names as "fetal rickets," "intrauterine rickets," "micromelic rickets," "cretinoid dysplasia," "defective endochondral ossification" and "rachitis congenita." The external characteristics of this disease resemble rickets in so many ways that the two conditions may readily be mistaken.

The confusion with cretinism is also not surprising because the physical features which accompany it are somewhat similar to those met with in achondroplasia. An achondroplasic child has distinct characteristics of its own. It has a large cranial vault, usually a pug-shaped nose; protruding chin; large abdomen; marked lordosis; short limbs, particularly referred to the humeri and femora; bowing of the bones; normal size of trunk and wheelspoke appearance of the hands; and, in contrast to cretins, an unimpaired mentality. The legs are always short so as to be out of proportion to the size of the trunk and this stunts the figure in an asymmetric way which is quite different from other varieties of dwarfism in which the limbs and trunk are shortened in relative degree. The arms also are too short-the finger-tips never reach to the level of the hips as in a normal person. Aside from being shortened these long bones are usually deformed and bent. The umbilicus marks the central point of a normal infant, while in the achondroplasic child the center is above that landmark, frequently as high as the ensiform cartilage, and this relationship continues throughout life. Nathan has observed that the dwarfism is only noticed on standing; when the child is in the sitting posture its height is not far short of that of an ordinary person of the same age. The abnormality of the head is confined to the vault of the cranium which is unduly developed and out of proportion to the face. The recession of the base of the nose is not due, as in congenital syphilis, to bone disease, but is produced together with the prognathus and disproportionate vault by premature ossification of the basis cranii. The hair on the head and body is abundant

and healthy, while the skin is well nourished and neither hard nor scaly. The fingers and toes are short and spatulate. The condition is always congenital.

The etiology of achondroplasia is entirely unknown. Rickets, syphilis and alcohol all of which have been given as causes at various times have not apparently anything to do with the disorder. Cretinism is also entirely distinct from it. Most cases are either still-born or do not survive very long; however, a number of cases in adults are reported. Keyser collected the history of 34 cases, 18 subjects were over 17 years, seven were over 30 and two were over 40 years. The disease is frequently hereditary.

Porak5 mentions the case of a woman who had the disease and gave birth to an infant similarly deformed. Porter records three cases, a father and two sons, the father at the age of 80 and the sons mature adults.

Boeckh also published a case of a female dwarf suffering from achondroplasia whose father and several other relatives had been dwarfs with similar proportions. In some cases it has been found that one or both parents, although not actual examples of the disorder, are neverthless of extremely short stature. The male sex is more commonly affected.

The pathology of this disease is now much better known than before. The internal organs show little or no change. The chief pathologic changes are in the skeleton and in that part of it ossified in cartilage. The bones, therefore, which are formed in membrane are usually quite normal, such are the flat bones of the cranial vault. The skeletal changes are mainly due to defective endochondral ossification and the bones affected are consequently the long bones of the limbs, the ribs, the innominate bones. and the posterior part of the base of the skull. Ballantyne, quoting Symington and Thomson, states that those bones which, although formed in cartilage, remain entirely or mainly cartilaginous till an advanced period of fetal life and the growth of which therefore is independent of endochondral ossification, show no abnormalities; such are the sternum, patella, costal cartilages, tarsal and carpal bones. The cause, whatever it may be, affects the infant very early, as the changes in the skeleton occur during the first few months of intra-uterine life. By the time the child is born the disease has run its course and is no longer active, so that the abnormalities seen are only the results of a malady which is passed. Ballantynes states that this and other forms of fetal bone