finally disappear.

7. The Achilles jerk, like the knee jerk, after it has been lost may reappear on one side before it does on the other.

CHANGES IN THE CORTEX IN ACUTE

MENINGITIS.

(Essai sur les alterations du Cortex dans les Meningitis Aigues, Pierre Thomas, Paris, J. B. Builliere et fils, 19 Rue Hautvefeuille.) The essayist believes that the part played by the vessels has been much exaggerated if not misunderstood. In his opinion the first changes are to be found in the larger and more highly specialized cortical cells. These, it is stated, show alterations before any change can be detected in the vessels, and with a severity which is in direct re⚫lation to the infectivity of the cause, duration of the infection and, apparently, the size of the elements.

The lesions which are described begin in the gray matter and extend to the vessels and meninges, and the pyramidal cells of the cortex are more susceptible to the virus of the pneumococcus and the tubercle bacillus.

LUMBAR PUNCTURE IN UREMIA.

Carriere, of Lille (Arch. Gen. de Med., Sept. 12), announces that he has found lumbar puncture a life-saving procedure in uremia. In four out of six cases it was of no benefit. He believes the value to be explained by the reduction of the pressure of the cerebro-spinal fluid and also the

time removes the poisonous fluid which is rritating the cerebral cortex. The cere bro-spinal fluid he has found to be invariably hypertoxic in nervous uremias. If edema or compression are evidently accountable for the condition, he considers them liable to be benefited by this means.

PERONEAL TYPE OF PROGRESSIVE MUSCULAR ATROPHY.

Walton (Jour. Nervous and Mental Dis., Sept., 1905, p. 573) reports a case occurring in a boy of 15 and having progressed very gradually since his 11th year. He comments on the difficulty of classifying this so-called "peroneal" or "family" type. He is of the opinion that the family history and physical examination of his case (aside from the reflexes) suggests a dystrophy rather than a spinal. or neural, type of atrophy. Three brothers also showed conditions analogous to the patient; the oldest, 25, has been afflicted 14 years, and while able to work, the muscles of the hands are wasted and the movements awkward, and as yet he shows no evidence of bulbar involvement. In the case described both feet are affected, the left somewhat more than the right; both feet are in a position of cavis. The muscles in the leg show diminished reaction to both currents. The knee jerks are sluggish and the tendo Achilles absent.

The author lays stress on the absence of fibrillary twitching even after prolonged examination. There are no sensory disturbances.

GEORGE A. MOLEEN, M. D.

INTRODUCTORY COPIES.

Any physician receiving The Journal without ordering same will know that one of two things has occurred-some brother M. D. has either paid us to send it in order to bring some article to his attention, or it is being sent for introductory purposes. In the latter

The

case, the magazine will be promptly discontinued at end of such period unless a signed order is given to have it continued. Journal is to be run upon modern, up-to-date ideas, and there will be no graft methods used in the circulation or any other depart ments.

S. T. MCDERMITH, M. D.,

Editor.

THE DEMAND FOR TRAINED EXAMINERS AND WHAT MEDICAL SCHOOLS ARE DOING TO MEET THE DEMAND.

"Be it Resolved, That the American Association of Life Insurance Examining Surgeons, assembled in Portland, Oregon, in regular session, July 10th, 1905, urge that each medical college in this country provide for and give in their regular course of instruction a special course of instruction on Life Insurance Examining, it being the desire of this association to advance the knowledge of this particular side of diagnostic work, and to prepare the recent graduate for this responsibility."

The resolution was adopted. Following are only a few of the points developed by the discussion of it:

"The medical student leaving college to-day is well trained compared with those leaving college with us; but he is trained to recognize pathological and not normal conditions."

"There is a vast difference between the examination of, say, the heart and large blood vessels, when one already suspects them to be at fault and when one, so to say, wishes to find them in perfect order." "The ear and mind construe sounds in different ways, as the causes are variously considered, and the same sound will be interpreted differently under the changed conditions; it will, therefore, be much wiser to mix healthy and diseased examples in the classroom, giving the student the best possible opportunity to study out the distinction."

"Students who aspire to become medical examiners in life insurance should be taught that life expectancy, or, in other words, the after lifetime of applicants, is the principal factor in the whole problem, for all calculations, whether financial or actuarial, are based upon the probabilities

JOHN ELSNER, M. D., P. J. MCHUGH, M. D., Consulting Editors.

of an applicant's outliving a given number or years.'

At the 1904 meeting (at St. Louis, Mo.) of the National Fraternal Congress the Medical Section of that body appointed a committee whose duty it was "To communicate to the various medical colleges of this country the necessity for such instruction," etc.

This committee sent out a circular letter to 166 medical schools in this country and Canada. Following are a few of the points which this letter brought to the attention of the school officials:

I. That in the United States and Canada there are about fifteen millions of insured lives, with over seventeen billions of dollars at risk.

2. That over two hundred millions was disbursed in 1904 in death claims, endowments and annuities to beneficiaries. 3. That in the same year the medical profession had an examining income from the business of seven millions of dollars.

(The foregoing to illustrate both the magnitude of the business and the tremendous responsibility resting on the examining fraternity in consequence of the sum at risk, which is so great as to almost induce vertigo.)

4. To the excellent opportunities which the business affords to young practitioners. This letter made it clear that the profession and the schools owe something substantial to this vast enterprise of life insurance to the intelligent selection of risks for the business, and that something is adequate training to fit the examiner to properly perform his responsible duty.

At the late session of the National Fraternal Congress held at Mackinac Island, Michigan, the chairman of that committee, Dr. F. A. Smith, medical director Modern Woodmen of America, made his

medical colleges.

2. Schools failing to reply, 78.
Replies classified thus:

(a) Number of schools which have chairs on medico-insurance or agree to add them, 38.

(b) Number that give limited instruction on the subject to their students, but

have not added chairs to their curriculum, 16.

(c) Number which give no such instruction, 26.

(d) Number desiring to further consider the advisability of it, 8.

The report summarizes thus:

"It will thus be seen that of the total 88 replies, 54 now give instruction to a greater or less extent. If the 78 which failed to reply are classed among those which give no such instruction it still leaves 33 per cent., or near one-third written to that are now giving instruction partially or fully.

"Our correspondence reveals that a number of schools are in doubt as to what the scope of such instruction should be,

The committee was continued with instructions to further urge the schools and induce as many more of them as possible to realize the overwhelming importance of measuring up to the needs of the hour in this important work.

Both associations that have sought to impress the need of this work on the medical schools universally agree that the didactic or clinical professor who is himself without practical experience in medico-insurance, is not the man to attempt to give this instruction. It should be some one who has worked out the problem by years of, at least, self training in practical experience, who realizes that the field and scope of the work practically amounts to a specialty in medicine.

LEONARD FREEMAN, M. D.,
E. J. A. ROGERS, M. D.,
R. W. CORWIN, M. D.,
Consulting Editors.

upon animals as well as the human subject.

The method long employed by physiolo gists, of rhythmically pumping air into the lungs through a tube tied into the trachea, the only method of operating under increased pressure known up to that time, had been tried by von Mikulicz, but his experiments upon animals had not been satisfactory.

After numerous experiments with different apparatus, the cardinal question of

the feasibility of such operations under negative pressure was demonstrated to the satisfaction of Sauerbruch. For a detailed description of the room used the reader is referred to the author's extensive article in "Mittheilungen aus den Grenzgebieten der Medizin und Chirurgie," Vol. 13, Tome 3, entitled, "Zur Pathologie des offenen Pneumothorax und die Grundlage Meines Verfahrens zu Seiner Ausschaltung."

All operations (and here we may say that the author distinguishes two methods, (1) anastomosis between oesophagus and stomach—“Esophago-gastrostomy," and (2) resection of the esophagus "Esophagotomy) were done in his newly constructed cabinet under a negative pressure of 10-12 mm. of mercury. Dogs exclusively were used for the experiments. The opening in the chest was made by means of an intercostal incision originally proposed by von Mikulicz at the last German Surgical Congress. According to Sauerbruch the three main factors of especial importance in the surgical work on the œsophagus are (1) strict asepsis, (2) substitution of the Murphy button for the suture, and (3) rapid production of adhesions by means of some such substance as Lugol's Solution.

Esophago-gastrostomy-Thirteen operations were performed in the following manner: Having exposed the œsophagus, great care is exercised not to disturb the anatomical parts surrounding and covering it. The double serous covering of the cardiac portion of the oesophagus, viz.: pleura and peritoneum, are incised at the foramen œsophageum; the stomach is then pulled into the thoracic cavity. A Murphy button is then introduced from without, and the stomach is thus anastomosed to the œsophagus. Careful suture with silk of the diaphragm to the portion of the stomach that has been pulled into the pleural cavity. Then the anastomosis, diaphragmatic sutures, and pleura, are

touched with Lugol's solution to induce rapid formation of adhesions.

All of the dogs operated upon recovered. Three died suddenly later. Autopsy in two of them showed that the stomach, much distended with fluids, had suddenly slipped into the pleura, compressing the heart. Careful suture will guard against this accident.

Resection of the Esophagus-Esophago-gastrostomy is done by means of the button, as before. Then the nervi vagi are isolated. The œsophagus is compressed with an intestinal clamp and ligated with a strong silk thread, and divided. divided. The same maneuver is done at lower end of portion to be resected. Inversion of the latter into stomach is accomplished by means complished by means of purse-string suture, with stitching of stomach against the upper stump in order to protect the ligature. The wound is then closed. Of eleven dogs operated upon in this way, every one recoverd.

It is of importance to note that Sauerbruch has tried all these methods on the human cadaver and found the anatomical relations exactly the same.

So far, the few resections of the oesophagus done on the human subject within Sauerbruch's box at the Breslau clinic (3 in number) have resulted in the patient's death. Hence we must confess that the direct practical value of these experiments of Sauerbruch is small. However, great good has already been derived. from the fact that the practicability of extensive surgical work upon the œsophagus has been established. More than this, the experiments show what can be done in the cabinet, and when one remembers that it is considerably less than a year that the new cabinet has been in working order, we can imagine the possibilities, not only in œsophageal, but also in the domain of lung, pleura, ribs, mediastinal and diaphragmatic surgery. -(Meyer, Annals of Surgery, May, '05,