and must furnish testimonials from responsible persons as to their professional and moral character. Assistant surgeons receive $1,600, passed assistant surgeons $2,000, and surgeons $2,500 a year. Officers are entitled to furnish quarters for themselves and their families, or, at stations where quarters can not be provided, they receive commutation at the rate of thirty, forty and fifty dollars a month, according to grade. For further information, or for invitation to appear before the board of examiners, address "Surgeon-General, Public Health and Marine-Hospital Service, Washington, D. C."

F. W. Vincent has removed his office from 1110 Euclid Avenue to 13527 Euclid.

The H. K. Cushing Laboratory of Experimental Medicine, of the W. R. U. Medical College, will be dedicated on Friday, November 20, 1908, at 2.30 P. M. Dr William H. Welch, of Johns Hopkins University, will give the address.

H. K. Yaggi, of this city, has removed to Salem, O., where he will take the practice of the late James Anderson.

Deaths

James Anderson, of Salem, O., died October 1, aged 57.
Z. F. Guerin, of Columbus, died September 15, aged 87.
Robt. S. Campbell, of this city, died October 17, aged 25.
L. Schooley, of Belmont, O., died September 17, aged 83.
William C. Hughes, of Cleves, O., died recently, aged 59.
John W. N. Vogt, of Delaware, O., died October 4, aged 56.
Henry F. Kattenhorn, of Cincinnati, died October 3, aged 39.
John H. Rogers, of Springfield, O., died September 28, aged 75.
A. W. Laybourne, of Springfield, O., died October 8, aged 90.
Arthur Kelty, of Youngstown, O., died October 9, aged 72.
Dennis McCarthy, of Dayton, O., died October 17, aged 87.
Elijah F. Davis, of Lakewood, O., died October 18, aged 79.
William C. Underwood, of Dayton, O., died recently, aged 41.
Lark Moon, of Columbus, died October 15, aged 42.

Wm. C. Pardee, of this city, died in Ashtabula, O., September 18, aged 54.

Pathologist, St. Vincent's Charity Hospital, Cleveland, Ohio

The term traumatic asphyxia suggests a striking clinical picture, but gives little conception of the true pathologic basis. underlying the condition. The cases thus far reported are relatively few and of these only several have been so exhaustively studied as to give us exact inner information. There is still a lack of pathologic definiteness in our knowledge of this extremely interesting condition. This is reflected in such terms as "pressure stasis," "Stauungsblutungen," "cervicofacial cutaneous asphyxia," "masque ecchymotique," etc.

The characteristic clinical picture has been admirably portrayed by those who have reported cases. The fact that it sometimes occurs after sudden crushing or compression of the thorax and abdomen for sufficient time to retard, or suspend respiration; that it is followed almost immediately by a marked cyanosis of the face and neck, associated with subconjunctival hemorrhages, superficially resembling asphyxia; that in most cases dyspnea is encountered and the sensoria dulled-all of these phenomena have undoubtedly contributed to the phrase "traumatic asphyxia." But when we come to examine this condition more carefully we find it differs in some important respects from true asphyxia. It bears a resemblance to such states we are accustomed to designate as ecchymosis, extravasation and subcutaneous hemorrhage, but also exhibits graded differences.

It appears from the literature that Ollivier1 in 1837, and in 1855 Tardieu2, drew attention to certain peculiar signs of the face and neck associated with some crushing injuries to the thorax and abdomen. They noted postmortem an unusual violet

Read before the Clinical and Pathological Section of the Academy of Medicine of Cleveland, October 2, 1908

tint of the neck and face, with subconjunctival hemorrhages, in a number of persons crushed to death by crowds, or suffocated in fire panics. The first complete description of this clinical picture, however, has been ascribed to Perthes3, after whom some have styled it "the symptom-complex of Perthes." He also pointed out the fact that a number of these cases in a few days developed pyrexia, rapid breathing, and bloody sputum, with scattered rales over the lungs. This he termed "contusion pneumonia." While conditions of this sort were recognized at least sixty years before Perthes, he must be given credit of correlating the symptoms, and of consistently reporting his observations.

When Beach and Cobb described their case of traumatic asphyxia in 1904, they presented but six other cases from the literature. It is gratifying to note that later Birge5 reported one of these rare cases before the Cleveland Academy of Medicine. When Lejars reported his case in 1905 he was able to collect from the literature 27 similar ones. W. Ettinger two years later cited 36 cases of traumatic asphyxia from reports he had collected. Since then several others have been added to the list. The condition is succinctly described by Criles in Keen's Surgery, where an excellent chromolithograph is to be found.

The clinical findings in all these cases have been so uniform -the differences being rather unimportant—that a brief summary is all that will be attempted here: (See summary, pages 656 to 659.)

1. Traumatic asphyxia has usually appeared in young and middle aged individuals of male sex and, as a rule, of healthy and robust constitution.

2. The nature of the injury has been a rather sudden compression or crushing of the thorax and abdomen for sufficient time to retard, or completely suspend, respiration.

3. If unconsciousness ensued it was usually for a brief period. A fair proportion of cases were conscious throughout, suffering only temporary disturbance of sight and hearing.

4. The associated injuries, in most cases, have not proved serious. The head and neck have been remarkably exempt. Fractures of the ribs were somewhat common.

5. The first records of temperature were either normal or showed a slight rise. A few cases have been subnormal. The temperature in one case (9) reached 101° F. The respirations have been variously reported as frequent, short, catchy, rapid,

shallow and labored. Most of the cases have had some dyspnea. The pulse has generally been small and frequent. On the second or third day some cases have exhibited a rise of temperature, frequent breathing and blood in the sputum.

6. The most constant and impressive feature of all the cases has been the uniformity in character and distribution of the color of face, neck and conjunctivæ-the "masque ecchymotique" of French clinicians. The patients all exhibited to a marked degree a violet-blue, bluish-black, or deep blue discoloration of the face and neck-of a finely mottled appearance. The intensity of color appears to have varied somewhat in the different cases. It was also deeper in certain regions of the face and neck, e. g., in some cases reported-more pronounced about the eyes, nose, mouth and ears. In several cases there remained a band of normal skin tint through the colored areas—in one it was noted around the neck where the collar-band compressed the skin, and in our case across the forehead where a stiff hat-band had caused similar compression. In the majority of cases the clavicles formed the lower limit of discoloration. Burrell and Crandon10 reported a case in which the color extended upward from the level of the third rib, over the neck, face and scalp. In Beach and Cobb's case the face and neck to the inner ends of the clavicles in front were involved, and the double angle of the trapezius muscle was distinctly mapped out behind. In Birge's case the discoloration extended upward from the level of the nipples.

The first impression is that this intense cyanosis is uniformly distributed and homogeneous; but closer inspection reveals a dusky bluish mottled appearance. Rather uniformly distributed over a dusky skin are minute (.5 to 1.0 mm.) areas of normal skin tint, each surrounded by a poorly defined bluish border. These appear, in some cases, associated with numerous minute reddish-violet spots, which led some observers to describe them as ecchymotic spots. Ettinger states that in his case the entire face, eyelids and neck were swollen and of a dark blue color. On the skin of the thorax he noted small and large blue spots. On the mucous membrane of the lips, cheeks, gums and pharynx there were numerous subcutaneous punctiform hemorrhages, and similar ones under the conjunctivæ palpebrarum. Upon pressure the blue color is made slightly paler but does not disappear altogether and it regains its former tint slowly when pressure is removed. In all reported cases there were marked subcon

junctival hemorrhages, giving to the scleræ a bright red or scarlet hue. In a number of cases the membrane bulged forward producing noticeable prominence of the eyes.

7. The eyelids in most cases have assumed a darker violet color. There has been moderate exophthalmos in many cases, and marked in a few. The subconjunctival hemorrhages were mentioned in every case. In some the pupils did not react to light. A few cases revealed minute retinal hemorrhages, while in others the vessels were merely congested. Vision was blurred in a fairly large percentage of cases, but no permanent disturbance of sight resulted. The sensoria in most cases were dulled.

A microscopic examination of the skin was made by Beach and Cobb, who found a marked distension of the small veins and capillaries, but no blood outside the vessel walls. They reported normal skin. Winslow 11 also found normal skin in his case, with distended, congested capillaries; but no blood outside the vessel walls. In our case we found a number of sections of the skin which were apparently normal, agreeing with former findings; but on studying carefully sections taken from the deeper colored area a few red blood-cells were found outside the vessel walls in the tissue spaces. The venules and capillaries were congested, but there was no injury to the vessel walls themselves.

9. Autopsy findings have been derived mostly from those persons crushed to death in crowds. In 1837 Ollivier1 examined. 23 of the bodies trampled to death in the crowd at the Champs de Mars, Paris. He reported a cyanotic violet discoloration of the face and neck in many of them and also mentioned that the dusky skin was "spotted with blackish ecchymoses." Fracture of the ribs was noted in seven cases. Subconjunctival hemorrhages were found in nine. The pial vessels and brain. substance were engorged with blood, but no definite brain lesions. were discovered. In other cases of sudden death, showing violet discoloration of the face with subconjunctival hemorrhage, the blood has been fluid and dark, filling all the veins leading to the right auricle. The viscera showed marked congestion, and the vessels and substance of the brain appeared engorged with blood. Punctate hemorrhages were noted into the loose tissues of the scalp, as well as on the surfaces of the pleura and pericardium. From some reports we are forced to believe that true ecchymoses into the skin have occurred. Most of the cases, however, appear