all been surprised at the confidence of the patients, and the ease with which they take the anesthetic. The patient will lie on the same table where the operation is to be performed. Without any struggling the anesthetic is taken, the patient is asleep, and the operation is done in less time than is ordinarily consumed. The fact that the surgeon who is to do the operation is in the room when the anesthetic is given, is of the greatest value, because the patient knows that he is to do the operation. I have had a number of patients ask me, especially clinical cases. "Are you going to do the operation?" That fact has made me believe that it is wrong to bring our patients into the operating-room asleep, but to put them asleep when they know you are going to do the work, and in the operatingroom. Another point that I think should be enlarged upon is the work of Dr. Crile. In addition to the use of adrenalin he has employed the pneumatic jacket. I think we should establish in our hospitals some better facilities for restoring patients by increasing blood pressure, and this jacket, as you all know, meets that want.

DR. R. C. DUGAN (Eyota): I want to say just a few words on this subject. Dr. Moore has always been an advocate of chloroform, and he has had marvelous luck with it. Anesthesia can be produced with ether just as well and just as quickly as with chloroform. I think Miss Magaw will put a patient asleep just as quickly with one as with the other. When anybody dies of chloroform he is dead, but when one dies from ether he is frequently not dead,there is a chance of reviving him.

DR. H. K. READ (Minneapolis): The matter of giving chloroform in the hospitals has been discussed, but there has nothing been said about operations in private houses. The surgeon sees the patient in the bed. It may be a corpulent patient, the husband may be away, and the chances are that a heavy woman must be moved from the bed to the table to be operated on. If the anesthetic is given in the bed, the chances are that the patient will wake up before she is put on the table. I think it is the proper thing to get that patient on the table, and give her the anesthetic in the room where you are going to operate, and thus you will not take the chances of having her wake up while taking her from one room to another. In nine cases out of ten where I am called upon to give an anesthetic I am expected to give it while the patient is in bed. I think it is more practicable for the physician and the patient that the patient should be put on the kitchen or dining-room table, or whatever may be used for the purpose, and be given the anesthetic there. The patient will readily consent if you will tell him it is better for him. This has reference to operations only outside of the hospital.

ON CERTAIN NON-DIPHTHERITIC MEMBRANOUS ANGINAS

LOUIS B. WILSON, M. D.

Minneapolis

Since the publication of Loeffler's1 classical work twenty years ago, in which he separated once for all the pseudomembranous anginas into the two great groups of those caused by diphtheria bacilli and those caused by organisms other than diphtheria bacilli, the attention of physicians has been directed almost entirely to those of the former group. This is rightfully so because of the much greater importance of the diphtheritic anginas. The latter group, however, should not be entirely neglected and there is a growing conviction that in it are contained certain diseases of which the cases, while not relatively numerous, are relatively important. It is the purpose of this paper to draw attention to some of these types of anginas, certain of which are not infrequently met with in routine examinations for diphtheria, and an interest may be aroused in them and more attention given to their study.

In considering the etiology of these non-diphtheritic anginas it should be premised that in none of them have Koch's postulates been entirely fulfilled. It has not been possible to reproduce in lower animals the exact symptoms as shown in man by inoculation of the organisms recovered from the human cases. The most that can be said of any of them is that the constant association of a certain type of microorganism with a certain type of angina, frequently almost to the entire exclusion of all other microörganisms and so abundant as to make up a large portion of the false membrane, is the principal evidence of their causal relation to the disease. The presence in the throat of healthy

persons of the organisms was taken by the older observers as prima facie evidence of their having little or nothing to do with lesions in angina, but while this fact makes more difficult the investigation, it can no longer be considered as disproving their etiological relationship since it has been shown that b. diphtheriæ also is present in a small percentage of the throats of healthy though exposed persons. Certainly it would appear that where two or more cases of pseudo-membranous anginas occur, similar in clinical symptoms and associated with similar organisms present in such numbers as to obscure or exclude others that their etiological relationship should be assumed as a working hypothesis and a careful clinical and bacteriological investigation conducted thereon.

Of the pseudo-membranous anginas which have been hitherto reported, there appear to be five types which have been found constantly associated with five different microörganisms that seem to be worthy of our attention at present. These are (1) those associated with streptococci; (2) those associated with diplococcus pneumoniæ; (3) those associated with Friedlander's bacillus; (4) those associated with the spirillum of Vincent, and (5) those associated with blastomyces.

GROUP I. CASES ASSOCIATED WITH STREPTOCOCCI

Isolated cases of diphtheroid pseudo-membranous anginas associated with streptococci more or less to the exclusion of other microörganisms are being constantly met with. No doubt they are frequently overlooked in routine examinations. for b. diphtheria, since Loeffler's blood serum, unless it is moist, is not a medium favorable either to the growth of the streptococcus or to its recognition when it does grow. In the routine work in the Minnesota State Board of Health laboratory streptococci have been found present many times in cases by subinoculation of broth medium when their presence had been only suspected from the examination of the Loeffler's serum culture. The clinical symptoms of this type of angina are sufficiently familiar to all, the onset being ordi

narily sudden with chill, slight fever and a white or grayish false membrane on one tonsil. Occasionally, however, the 'temperature becomes much elevated, the membrane may spread, involving both tonsils and the uvula, prostration become marked, and death may occur in two or three days, or when recovery takes place the convalescence is apt to be very slow. In this latter type of cases, blood cultures where made have not failed to show a streptococcemia. One of the most striking series of cases is that reported by Prudden, who made bacteriological examinations of 24 fatal cases of pseudo-membranous anginas occurring in two hospitals for children in New York. In none was b. diphtheriæ present while streptococci were found. Several epidemics of this variety have been reported also by European observers. One of these reported by Cassedebat occurred among soldiers in a garrison where among two thousand men, one hundred and thirty-four cases developed in a few months. These were shown to be associated almost exclusively with streptococci though occasionally staphylococci and pneumococci were present with the streptococci. Cassedebat thinks that there was abundant evidence in this outbreak to show that the cases were "contagious." Probably the largest epidemic reported is that by Le Damany. This epidemic occurred in the town of Rennes, which had at that time a population of seventy thousand. From December, 1898, to June, 1899, more than three thousand cases occurred. One hundred of these were carefully studied bacteriologically as well as clinically. Streptococci were present almost to the entire exclusion of other organisms and where deaths occurred, streptococci were found in the various organs at autopsy. Le Damany believes that the evidence is quite sufficient in this outbreak to establish the fact of the "contagious" character of the disease. He notes that scarlet fever was present in the city during the period of the epidemic of angina, though he was careful to exclude the possibility of its relationship to those cases which he described as pure streptococcic angina. This coincidence of severe streptococcic anginas with epidemics of scarlet fever has been noted by

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many observers and is of special interest in relationship to the recent observations of Hektoen1 and others on the probably constant association of streptococcic septicemias with fatal scarlatinas.

GROUP 2. CASES ASSOCIATED WITH DIPLOCOCCUS PNEU

MONIE

That the diplococcus pneumoniæ, originally described by Sternberg as a "virulent micrococcus in the salivary secretions of healthy individuals" and by Frankel as the "micrococcus of sputum septicemia" is frequently associated with mild and severe pseudo-membranous anginas there can be no doubt. Like the streptococcus it is frequently missed in routine examinations of cultures on Loeffler's blood serum, since the medium is unfavorable to the development and recognition of the microorganism. The only epidemic of importance is that reported by Vedel' in which five cases occurred with three deaths. The clinical symptoms were not unlike those of streptococcic angina or diphtheria and were at first mistaken for the latter until frequent examinations had excluded the diphtheria bacillus as the etiological factor. The relatively high mortality and apparent contagiousness of these cases is interesting in relationship to the recent observations on the invasion of the blood by pneumococci in pneumonias and the apparent transmission of pneumonia by sputum.

GROUP 3.

CASES ASSOCIATED WITH FRIEDLANDER'S BACILLUS

Several cases of angina with initial symptoms of dysphagia, temperature 101° to 103°, anorexia, depression, intense local inflammation, and the final formation of a firmly adherent membrane have been reported by various observers, as associated with Friedlander's bacillus. One small epidemic in which the cases presented the above described symptoms is reported by Nicolle and Hebert. All of the five cases were rather severe but none of them were fatal. The bacillus of Friedlander was isolated in pure culture and proved to be virulent on animal inoculation. Mayer" reports,