being made at each point. If the two tests at any point differ by more than 0.15 degree F., or if the mean of the two tests gives a correction in excess of 0.3 degree F., the thermometer is rejected. Furthermore, errors in the intervals between test points must not exceed 0.3 degree F. For example, if the correction at 96 degrees is + 0.3 degree and at 100 degrees - O.1, the error in the interval would be 0.4 degree F. and the thermometer would be rejected. Twenty-four thermometers are mounted in one of the small holders shown in Fig. 1. The loaded holder is placed in a tank of water heated to a temperature of 96 degrees. The tank used by the Bureau of Standards is quite intricate in construction, is heated by an electrical coil, and is so designed as to insure the retention of the water at any temperature that is desired. This tank appears in the centre of the table in Fig. 2, which shows a complete set of the apparatus used for testing clinical thermometers in the Bureau of Standards. This table. by the way. forms a portion of the exhibit of the Bureau of Standards in the Government Building at the St. Louis Exposition. The holder is then taken out r and placed on the stand shown in Fig. 3, to which is affixed a micrometer eyepiece. Reading through this eyepiece, the location of the index is very accurately and rapidly noted, an assistant taking down the figures called out by the ob server. The loaded holder is then placed in the centrifugal machine, or whirling device, which is shown in Fig. 4. By a series of experiments, the bureau has determined the rate of speed at which this apparatus should be turned in order to equal the average force exerted in shaking down or resetting the index of the thermometers, and if the index fails to return when the machine is turned at the indicated speed, showing that the index is too difficult to shake down, the thermometers are rejected. The holder is again placed in the water bath and a reading taken at 100 degrees, the results are noted, the index is shaken down by means of the whirling device, and observations are made at 104 degrees and finally at 108 degrees. This process is repeated so as to give two readings for each thermometer at the same temperature. A careful comparison of these readings enables the operator to formulate certificate for such of the thermometers as are acceptable and to determine which should be rejected. The results of these examinations are furnished to the maker or dealer who submits the thermometers, in a tabulated form, so that they can always be referred to when necessary. A reduced facsimile of such a tabulated statement is presented in Fig. 5. For much of the information contained in the foregoing note, and for the illustrations, I am indebted to Mr. S. W. Stratton, chief of the Bureau of Standards, who has kindly permitted me free use of advance sheets of a monograph describing the work of the bureau, written by L. A. Fischer and C. W. Waidner. I am also indebted to several of the manufacturers of clinical thermometers who are interested in the elevation of the character of the thermometers on the market. Since I have said so much in criticism of the commercial thermometers, it is but justice to the manufacturers to state that some of them have displayed the keenest interest in my work and have given me every assistance and encouragement in my effort to bring about a betterment in the character of the clinical thermometers of the market. The need of greater care in the purchase of clinical thermometers having been pointed out to pharmacists and physicians, it is to be hoped. that an improvement will take place in the character of these goods as generally found in the market. same birth being known." Lusk2 reports one case of quintuplets; so does Volkmann, of Düsseldorf, Germany. Aristotle long ago stated that more than quintuplets at one birth do not occur. A case of sextuplets, reported by F. B. Osiander, was denied in the second edition of his book, edited by his son, J. F. Osiander. The case in question was that of a woman in Silesia, who, for purposes of deception, had collected six of her miscarried fœtuses and 'had stated that she had borne the six fœtuses at one and the same time. As a contribution to the literature of this rare occurrence, I will add the following case of the birth of quintuplets. The history of the birth and a short biography (!) of the quintuplets is as follows: O. D. L., father of the quintuplets, was born in Logan County, Kentucky, in 1849. The mother, E. C. L., was born in 1857, in Warren County, Kentucky. They were married in 1874 and removed to Graves County, Kentucky, in 1888. From 1875 to 1893 seven children were born; at the time of the birth of the quintuplets the oldest of the children was over 20 years of age, the youngest 22 years old. All the children are living, with the exception of the second youngest. On the 29th day of April, 1896, the late Dr. S. J. Mathews, of Mayfield, Ky., was called to attend Mrs. L., and he delivered her of five living boys within one hour. As Dr. Mathews told me personally, the individual children followed one another at intervals of ten or twelve minutes. The weights of the children (in order of the birth) were 4, 44, 44, 44, and 5 pounds. Birth occurred in the eighth month of pregnancy. The children were apparently healthy and well developed. Dr. Mathews could not give any reason why the children died, unless it was the fact that after their baptism on May 3rd, they were, while being taken into the yard to be photographed (Fig. 1), exposed to the cold air. The first of the quintuplets died May 4, 1896, at 3.20 p. m., having lived 4 days, 17 hours, and 20 minutes. The second followed May 11th, at 6.30 a. m., aged 11 days, 8 hours, and 30 minutes. The third died May 12th, at 11.30 p. m., aged 13 days and 2 hours. The fourth died May 13th, at 2.30 p. m., aged 13 days, 18 hours, and 30 minutes. Lusk, Science and Art of Midwifery, p. 228. Volkmann, Centralblatt für Gynäkologie, 1879, No. 17. Other cases of quintuplets have been reported by Krebs, Monatsschrift für Geburtshilfe, vol. 3, p. 236; Spiegelberg, ibidem, vol. 7. p. 463; Fleischer, ibid., vol. 9, p. 149; Galopin, ibid., vol. 31. p. 475, and Sproule, Cannstatt-Virchow's Bericht for 1867. vol. 2, p. 579. The fifth died May 14th, at 12.30 p. m., aged 14 days, 2 hours, and 30 minutes. The bodies were embalmed and are kept in a glass case. The afterbirth consisted of five placentæ, grown together, and each has, as Fig. 2 shows, a separate umbilical cord. The mass of these five placenta. the weight of which in their fresh condition I could not find out, is also preserved. The third figure shows the children within the fœtal membranes. The births of the individual children followed, according to Dr. Mathews's personal statement, in the order shown from I to 5. The mother is rather a small woman; she is 5 feet 1 inch in height, and her usual weight is 112 pounds. In the final three months of this last pregnancy she was almost helpless, and after the delivery she recovered very slowly. Referring to the case mentioned above, Dr. Volkmann tells of a memorial tablet, showing Christ on the cross, beneath a kneeling couple and seven dolls representing seven babies, and an inscription (a translation of which is given below), having been found on a house in Hameln in Germany: Here lived a burgher, Thiele Roemer, famed, To them were born two boys and maidens five Remarks on the Etiology and Treatment of Diabetes Mellitus.-Futcher, in the Maryland Medical Journal, for September, 1904, gives the following as the views which are now entertained concerning this disease: It is held to be due to some primary blood change by which the red cells are made more vulnerable, permitting them to distintegrate more readily and to give up their hæmoglobin. This blood pigment is deposited mainly in the gland cells of the liver and pancreas, as well as elsewhere in the body, leading, in a certain percentage of cases, to definite bronzing of the skin. As a result of the local deposition of the pigment in the liver and pancreas, a chronic interstitial inflammation of these organs is produced, which leads in the case of the liver to a hypertrophic pigmentary cirrhosis, and in the case of the pancreas to an interstitial pancreatitis of a pigmentary type. In the early stages, or early years of this affection, sugar does not appear in the urine. and it is only when the changes in the pancreas become so advanced that the islands of Langerhans are largely or completely destroyed, that glycosuria and diabetes develop. SYPHILIS CONTINUOUSLY TREATED BY INTRAMUSCULAR INJECTIONS OF MERCURY SALICYLATE.* By D. A. SINCLAIR, M. D., NEW YORK, LECTURER IN GENITOURINARY DISEASES AT THE NEW YORK POLYCLINIC MEDICAL SCHOOL AND HOSPITAL. Intramuscular injections of salicylate of mercury, as a continuous method of treating syphilis, is the subject which I wish to bring before you this evening. In advocating this particular drug and its method of administration I have not lost sight of the fact that the other well known methods, namely, inunctions, internal medications, per ora, and fumigations, have their places, and that all are of undoubted excellence; but, after all is considered for and against all of the methods enumerated, I have personally arrived at the conclusion that the hypodermic or intramuscular method is the most satisfactory and can be used with more gratifying results in a larger majority of cases than any of the other methods mentioned, and, briefly, for the following reasons: Inunctions: While this method of treatment is efficacious, I, personally, have been unable to induce patients to follow the treatment for more than a few weeks or a month on account of the difficulty and the filthiness in its application, and of its compromising character. In order faithfully to follow the rules laid down by its ardent advocates. all parts of the body must be systematically gone over. The back is the one part of the anatomy which obviously is rubbed with difficulty, and patients usually have to call on some friend to do this particular treatment for them. This is not always a desirable or an easy thing to have done, and, if the patients go to professional masseurs, in the language of one of our most respected syphilographers, "the masseur absorbs. the patient while the patient absorbs the mercury," and so, of necessity, I have given up this particular method of treatment. The internal administration of mercury is, I believe, the most common method of administering mercury, and the preparation most frequently used is the protoiodide in tablet form. This method is, in my opinion, less efficacious than treatment by inunctions, and has its disadvantages. To begin with, it is slow of action and unscientific, as we never know exactly how much of the drug is absorbed. It is impossible for many patients to take a dose large enough to control in a complete manner their syphilitic lesions because of gastrointestinal disturbances; and I believe it is * Read at the Celtic Medical Society, Academy of Medicine, New York, May 26, 1904. a prolific source of tempting the patient after a short time to treat himself, thereby placing him out of the reach of his medical advisor, with the usual results that he almost invariably ceases treatment altogether, and in later years discovers that he still has syphilis. cases. Fumigations I will pass with a word or two. From what I have read, they are said to be very efficacious, but seldom used, except in desperate I have never had occasion to resort to them, depending on and always succeeding with the intramuscular injections of the salicylate of mercury in getting complete control of any syphilitic manifestations. Injections, intramuscularly, of salicylate of mercury possess many advantages over the other methods mentioned. They are more scientific and accurate, in that we know how many grains we give at each injection, as if it were morphine, strychnine, or any other of the familiar drugs. The gastrointestinal tract and the skin are relieved of the irritation often involved in these avenues of medication. They are quick and sure in action, the symptoms disappearing with wonderful rapidity. They are applicable in all three stages of the disease, non-compromising, easy in administration, cheap to the patient and doctor. They enable us to control the patient in a most complete manner; they do not produce abscesses; and have to be administered but once a week, due to their insoluble properties and slow absorption, which enables us to use a larger amount at a given dose than we could use of the soluble salts of mercury. The use of intramuscular mercurial injections is admitted by nearly all observers to be a very potent method of treating syphilis, but it is usually spoken of as a method of reserve or of utility in treating desperate or refractory cases, which do not yield readily to other forms of treatment. I should like to know why this method, which is admitted to be so efficient in stubborn cases, should not be used as a routine form of treatment. As far as I can see, the reasons for the non-adoption of intramuscular injections are not well founded. In the salicylate of mercury we have a salt, insoluble in character, which needs to be injected but once in seven days, and which does not produce abscesses. If the physician will take the time and pains to explain the advantages of this method to his patients, I feel sure he will be better able to hold them; and I can positively say that I never lost a patient on whom I used this treatment, whom I could have held had I employed inunctions or internal medication instead; for I make it a point to tell my patients the advantages and disadvantages of each form of procedure, giving them their choice, but strongly advising the injections, and tell them, if they feel that the injections are too severe, I will put them on one of the other treatments. The result is that I succeed almost without exception in keeping up the injections, because the patients are amazed and pleased at the visible improvements which take place after a few treatments are given, and, in case they have to go away, when they cannot take the injections, and are put on inunctions or pills, they always prefer to go back to the injections; and hence I feel justified in saying that the inunction, fumigation, and internal administration of mercury are methods to be held in reserve for the patients who cannot or will not be injected. Relapses, though extremely rare, I have seen, even when the injections were given weekly, and I now believe they were due to one cause only, viz., to the smallness of the dose. I have given over six hundred injections and here report the disadvantages. Disadvantages of injections: In five instances in my experience, I have noted a series of phenomena following immediately after the injection, within, I should say, twenty seconds. The patients started with a short, dry cough, similar to that produced by the inhalation of some irritating fumes. This was accompanied by a slight tightness in the chest, bordering on pain, and a very slight faint feeling; a hunger for air, so to speak, a feeling of nausea, without vomiting. In one case, lasting for twenty-four hours, the patient said that he spat up blood streaked sputum. The phenomena in the four other cases passed away in from fifteen minutes to one hour. There was nothing alarming to me in these phenomena; I think that they were due to a globule of oil or a small bubble of air being carried by the circulation into the capillaries of the lung, and I have repeatedly injected these same patients, without finding a single bad result remaining. I feel that it is absolutely important to call attention to these observations. We are also liable to observe a general feeling of malaise, with loss of appetite, coming on in twelve hours, and lasting about twenty-four hours. This is more noticeable especially after the first two or three injections. In a few instances I have observed a slight rise of temperature; 99.5° to 100° F. The local phenomena, immediately following the injection, are in nearly every case nil, although rarely we may have a slight pain, due to the introduction of the needle; but whether present slightly or not at all, in a small number of cases there is apt to follow, in from six to twenty-four hours, a slight lameness, with dull pain, more or less severe, at the site of injection. This may be accompanied by an itching or burning subcutaneous nodule. Now, the former condition, which is by no means frequent, and mostly noticeable after the first few injections, is generally ephemeral in its course, but the subcutaneous nodules, which vary in size from a hazelnut to a walnut, may remain from a few days to a few weeks, never suppurating, and invariably disappearing completely. When these nodules cause the patient any pain, I advise him to apply hot cloths and to use gentle massage. The mouth and gastrointestinal tract I have never seen affected from the injection of salicylate of mercury in a dose of one grain and a half, but I have on several occasions produced a mild mercurial stomatitis and diarrhoea, the latter consisting of about eight passages in the twenty-four hours. This, however, was due to my desire to get in a telling blow by administering an amount of mercury larger than I here give as the regular weekly dose. However, these phenomena never were serious enough or lasted long enough to cause the slightest alarm. The preparation known as salicylate of mercury was first used in 1887 by Sylva Aranjo. It is a fine, white powder, insoluble in water, the dose being internally from one quarter to one half grain, and, as an injection in ordinary cases, one grain and a half. In selected, severe cases, I have injected six grains without any but the most gratifying results. The drug, when used, should be suspended in a heavy liquid. The formula I use was first introduced by Dr. Keyes and Dr. Chetwood ten years ago, and is most satisfactory. It is put up in drachm vials, each containing one grain and three quarters of the salicylate and about thirty minims of the liquid benzoinal, so as to insure cleanliness and accuracy of dosage. The amount remaining in the phial, after it is poured into the syringe, and the small amount which sticks to the syringe, equals about one quarter of a grain of the mercury, so we really inject one grain and a half. When this combination is shaken, the mercury will remain suspended for several minutes. The technique which I follow, and the apparatus for carrying it out in detail, are very simple. An alcohol lamp, a sixty minim subcutaneous syringe; a needle of large calibre, which should have. a high polish, a sharp point, and be about No. 19 gauge, and an inch and a half long; cotton; ether or alcohol; and collodion are necessary. The site most favorable for the injection is the gluteal region, but this may be changed to the calf of the leg or the muscles of the back and chest. The part selected for the injection is bared and cleaned with a piece of cotton, moistened with alcohol or |