became a prominent symptom. There was tenderness over the epigastric region, but no tumor could be outlined. At the autopsy the external contour of the organ was normal, but on section, the lower third was the seat of an annular thicknening which was in some portions as much as 4.5 cm. thick, and causing considerable diminution in the calibre of the organ, but no obliteration. Oct. 3, 1900, a blood examination showed the following: Hb., 52; red cells, 2,000,000; leukocytes, 5,600. Differential count: large lymphocytes, 21 per cent.; small lymphocytes, 30 per cent.; neutrophiles, 37 per cent.; eosinophiles, 4 per cent.; basophiles, I per cent.; myelocytes, 7 per cent. Normoblasts, megaloblasts, poikilocytes and Grawitz degeneration of megaloblasts were present. The patient died Oct 29, 1900. Her insanity was Section 8 hours after death. Unfortunately permission to examine the brain and cord could not be obtained.

mania.

Anatomical Diagnosis. Mitral insufficiency, degeneration myocardium; emphysema of lungs; anæmic kidneys; metastatic carcinoma of liver; carcinoma of stomach; metastatic carcinomata of mesenteric lymph glands; chronic interstitial pancreatitis; cystic ovaries; and proliferation of bone

marrow.

Histologically the bone marrow showed the characteristic changes of pernicious anæmia.

SUMMARY.

I. and II. are the cases whose mental condition it is considered may have been due to the pernicious anæmia. In the case of the Italian fruit pedler (Case II.), there was a history of an admission to a hospital several years previous, and at which time, it was later learned, he had pernicious. anæmia. He recovered and was discharged. Presumably with a remission of the disease we have a return of the mental symptoms followed by death.

Case I., to be sure, gave evidence of syphilis, as shown in the syphilitic hepatitis and, perhaps, also in the chronic

pachymeningitis, but it is to be remembered that her mental condition greatly improved under treatment directed to the anæmia.

Cases III. and IV. did not develop the clinical symptoms of pernicious anæmia until after a hospital residence of several years. At the period of their admission it was not the custom to make systematic examination of the blood. It is impossible, therefore, to state the condition of the blood at that time. But the apparently fairly good physical condition of the two cases, despite the hypochondriacal delusions of one case which have been present since admission, warrants the assumption that the nervous and mental disturbances were etiologic factors in the pernicious anæmia of these two cases.

The influence of pernicious anæmia in the production of nervous and mental disturbances was advanced by Lepine", Wilks, Coupland, and subsequently illustrated in cases reported by Curtin. Ewing, however, in his recent work "the functional disturbances of the nervous system cannot be claimed to act as more than somewhat distant predisposing causes."

states that

Of Case V., which is the one tentatively added, I would state that annular carcinomata of the pylorus have been frequently seen at autopsy where the blood had shown before death the typical changes of pernicious anæmia.

planation of which is advanced (Ewing) "that there is a rapid and general or slow and partial establishment of the marrow changes."

Spinal symptoms were not prominent features of any of the cases in the series.

REFERENCES.

1. Bromwell. Anæmia and Some Diseases of the Blood-forming Organs and Ductless Glands, p. 92, 1899.

2. Cabot. Clinical Exam. of Blood, p. 130, 1897.

3. Ewing. Clin. Path. of the Blood, p. 372, 1901.

4. Leichtenstern.

Ziemsenn's Handbook Bd. 8, p. 344. Cited by Ewing.

5. Lichtheim.

Zur Kentniss Perniciosen Anæmia. schr. xxxiv, 301.

Munich Med. Wchn

6. Cited by Stengel XX. Cent. Practise Med., vol. vii., p. 380. 7. Putnam. Jour. Mental, Nerv. Diseases, Feb. 1891.

8. Dana.

Jour. Mental, Nerv. Diseases, Feb, 1891 and Jan., 1899.

9. Dana. Text-Book Nerv. Diseases, p. 299.

10. Putnam and Taylor. Jour. Ment., Nerv. Diseases, Jan. and Feb., 1901. 11. Bastinelli. Bul. Della Royal Acad. Med. Di Roma, 1895-6, Pasciolo I., II. Cited by Putnam and Taylor.

12. Adami. Annual Address Soc. Internal. Med., Chicago, Nov. 29, 1899.

13. D'Abundo. Cited in Progress Neurol. Boston Med. Surg. Jour. April 18, 1901.

14. Fuller. N. E. Med. Gazette, June, 1900.

15. Ashford. Army Notes, Boston Med. Surg. Jour., April 12, 1900.

16. Chapirow. Med. Press, Jan. 25, 1888.

17. Cabot.

Boston Med. Surg. Jour., May 24, 1900, p. 546.

18. Grawitz. Am. Jour. Med. Science, Sept., 1900, and Deutsches Archiv. f. Klin. Med., 1900, No. 67, p. 357.

19. Lepine, Wilks, Coupland, Curtin. Cited by Stengel, loc. cit., p. 365. 20. Ewing, loc. cit., p. 183.

THE PLAGUE IN INDIA. In conclusion I will briefly review the lessons to be learned from Indian experience of plague and the difficulties to be contended with. The lesson which stands out in large letters is that the compulsory measures attempted have failed to have the desirable repressive effect on the disease, because the populace have, to a man, been dead against them and the authorities. . . . The main line of objection to plague measures have always been a dread of segregation, with separation of members of families; and Government orders that no wife would be separated from her husband, or a mother from her children have not succeeded in inspiring confidence. The people display an absolute apathy and indifference to plague, as a rule, but let the Government suggest means by which they may be spared the affliction and a panic ensues. Cases of illness are concealed with every ingenuity, and each one vies with his neighbor in giving false information. Violation of caste is made an excuse for objection to any preventive measures, such excuse having no foundation. Facilities have been

given for the institution of private and caste hospitals, but no advantage has been taken of them. Ignorance, distrust and predjudice have held their sway, supported by superstition. Major H. E. Deane in Calcutta Journal of Medicine.

MODERN SURGICAL TECHNIQUE.

BY GEO. H. EARLE, M. D.

The title of this paper hardly indicates what is in the writer's mind to say.

My wish is to compare, very briefly, the present surgical methods, in operating, with those which prevailed in the old days, that is fifteen or twenty years ago.

You are more or less familiar with the present methods. I mean the various plans and devices by which the field of operation, the instruments, dressings, and the operator's hands are made clean. Cleanliness is recognized as the one thing for which to strive. But let us look back for a few moments along the road we have traveled and note some of the milestones by the way.

We, as homœopathic physicians, have much to be proud of in this connection, for here in surgical therapeutics, as well as in medical therapeutics, time is proving that "the mild power is greatest." What was embraced in surgical technique twenty years ago? Would not the term dexterity and celerity in operating cover it? Very nearly if not quite.

Pardon me a personal reminiscence. Less than twenty years ago, in the amphitheatre of the great institution just. across the way, the surgeon does an amputation of the thigh, clad in a blood-glazed frock coat, which had evidently seen long service, and which, between times, hung on its hook behind the door. If he washed his hands before operating it was not evident, and he certainly handled the coat the last thing before beginning. That, to be exact, was seventeen (17) years ago this winter.

Operations upon the eyes were performed, the various instruments sticking in the hair of the operator between times. At that time the surgeons in our hospital had adopted the use of clean, white frocks, while operating. These same frocks were a source of more or less amusement to our friends, and styled by them "butcher frocks."

Operations were performed in the room below us, where perhaps an autopsy had been held the day before, and where anatomical specimens were in daily use for the purposes of teaching. The "cleaning up" process consisted only of a few flourishes of the janitor's mop.

From that time to the present, what has not been done in the way of inventing antiseptics? The complicated and cumbrous technique of Lister. The spray, douche, mercu. rial compresses, etc., etc. What violence has been done to tender, bruised and vulnerable tissues in the name of antiseptic surgery! For instance, an amputation of the leg, done with a stream of mercurial solution running over the field of operation during the entire time. The result is a shoughing of the flaps with mercurial ulceration, absorption of the infected material, and death from septicemia.

In obstetric practice it became fashionable among the extremists to administer an intra-uterine mercurial douche after any interference, instrumental or manual, within the uterus. This was done as a prophylactic against infection. Several deaths, with distinct symptoms of mercurial poisoning, discouraged this plan as a routine method

I can remember that, as a student, I came to feel that antiseptic surgery practically meant the soaking of everything in a solution of carbolic acid; and that when a surgeon ventured to operate, after a simple cleansing of the field of operation, and with his instruments lying in a pan containing clean water and so harmless a drug as calendula, I gasped at such foolhardiness.

But what has the result of all this effort and experiment been? Just this. That asepsis is recognized in all departments of surgical work as the ideal to be striven for, and that any plan of antisepsis is only a means to that end.

Some of the essentials of modern surgical technique are: Great care in cleansing the hands and field of operation with soap and water and friction. Simple boiling of instruments. Live steam under pressure for dressing and sponging material. The least possible handling and the protection of