unequivocal signs of an organic lesion of one pyramidal tract; and, reasoning by induction, we conclude that the accompanying paralysis is organic. In this conclusion we have not considered the paralysis itself; we have left it quite aside and thought only of the certain signs of organic lesion of the nervous system. There is every reason to conclude that paralysis associated with these certain signs of organic nervous lesion may be organic wholly or partly; but their association is in itself no demonstration that the paralysis is wholly organic, for the reason that one or more of these certain signs of organic nerve-lesion may exist and prove that there is an organic lesion without any paralysis. Therefore, in order to appreciate the organic or functional nature of paralysis, or the possible association of the two varieties, we must study this symptom in relation to essental peculiarities that will aid us in deciding the point at issue and afford important elements for prognosis.

Studying the paralysis in itself, let us take a case in which the arm is in a state of limp palsy. Now this loss of power may be due to idea (functional) or to a material nerve-lesion (organic). The arm hangs limp and inert, obeying the law of gravity, and it may be moved about passively with no other resistance to overcome than the weight to be moved; and since the joints are "loose" a flail-like movement may be passively induced.

If this flaccid, relaxed state be due entirely to an organic nerve-lesion, since the latter is unchangeable, the resulting condition of limpness of the arm will not vary; under all circumstances it will present the same peculiarities. If on the other hand, the limpness or flaccidity vary momentarily or from time to time under observation, we may safely conclude that the paralysis is not entirely organic; and if, besides, there be no other sign of organic nerve-lesion (abnormal reflexes, muscular atrophy, etc.), we may safely infer that the paralysis is entirely functional. To appreciate practically this point, the observation must be repeated and made very carefully; and we must resort to procedures the object of which is unknown to the subject. For example, in the case of flaccid brachial palsy under discussion, the observer raises the arm passively to the level of the shoulder and maintains it there, carefully noting the effort required and the sense of weight experienced with each repetition of the maneuver; on each occasion the arm should ultimately be allowed to obey the force of gravity. In case of organic paralysis the arm will return immediately to its original position. If, during the test, the arm remain for an instant extended without support; if there

be any variation of the force necessary to raise it to a horizontal position, we know immediately that voluntary nervous power has intervened to cause a variation from absolute inertness, and that there is certainly functional paralysis, no matter what other signs indicate the probability of some degree of organic paralysis. This procedure tests merely the deltoid muscle, but by appropriate manipulation we can test similarly other muscles of the limb. In order to make the results of such experiments convincing, the attention of the subject should be dis.racted by conversation, or otherwise, from the maneuver to be carried out.

With respect to brachial paralysis, whether due to central or peripheral nerve-lesion, it should be mentioned that in many such cases, if not in all, a state of muscular hypotonicity exists which permits passive overflexion of the forearm on the arm (Babinski). When this condition exists, since it is a feature that belongs to paralysis in itself, because it depends upon the muscular condition, we may be sure that we have before us a symptom caused by nerve-lesion, unless it can be explained by idiopathic atrophy of the muscles concerned; for it never occurs unless made possible by practice or as a natural peculiarity of several joints, except as a result of the causes mentioned. Muscular hypotonicity never results from hysteria. The practical value of this sign of hyperflexion of the forearm on the arm depends upon its occurrence on the paralyzed side as compared with its absence on the opposite side, and the fact that the degree of passive flexion of one elbow is readily compared with that of the other. Doubtless in cerebral palsies the same hypotonicity exists in other muscles than those concerned in overflexion of the arm at the el

bow, but is it less apparent because the conditions for comparison at other joints are less favorable.

In contrast with the limp paralysis just considered, let us next examine a case of spastic or stiff palsy of the arms.

The sign of over-flexion of the forearm on the arm has here the same value as in the preceding case-it indicates organic lesion as a cause of the paralysis.

Again, similar careful examination for spontaneous variations of the apparent loss of power should be made; and such variations, in the presence or absence of other signs of organic nerve-lesions, prove that the paralysis is partly functional or incomplete.

In this case there are still other elements to be studied; namely, the peculiarities of the stiffness (spasticity, contracture) presented.

Spasticity or contracture of muscles due to organic nerve lesion is not subject to sudden variations of degree, though it is at certain periods characterized by gradual increase or decrease extending over weeks or months. But the contrary is true of functional contractures and therefore, spasticity that presents momentary or occasional variations affords a positive indication that it is dependent upon a functional cause.

In order to convey the full meaning of this difference, an actual case of hysteric (functional) contracture and paralysis may be cited. The lower extremity is found in a state of rigid semiflexion involving thigh, leg, and foot, so that the whole limb seems actually subject to a permanent deformity. Under an anesthetic the limb is forcibly straightened and placed in a cast; finally the limb is released, and all contracture is found to have disappeared. If this operation in such a case has not been attended by physical injury (rupture of muscles, tendons, etc.), and the limb presents normal muscular tonicity after it, the result is a demonstration that the original contracture was functional. In a similar case of contracture due to organic nerve disease, while mechanical force might temporarily overcome the deformity, the latter would immediately return when the modifying force had been removed.

Spasticity and contracture due to organic nerve lesions present other characteristics that serve to differentiate them from similar conditions due to functional nervous disease. Contracture due to organic nerve-lesion, while practically permanent, may be gradually overcome for a time by an effort that opposes it; with the effort made to extend the fingers flexed in contracture, for example, there is a gradual and progressive relaxation of them, and in the operation the examiner experiences the sensation of overcoming a purely mechanical and diminishing resist ance. Extension once accomplished, and the fingers released, they gradually assume the previous state of flexion. In a similar case due to a functional cause, with a similar procedure, the result is quite different. The effort to overcome passively flexion of the fingers encounters gradual or sudden increase of resistance-a positive variation of the force of contracture-to overcome which great force may be required. Such a variation is absolutely indicative of the functional nature of the contracture.

Again, with the fingers in a fixed position of flexion and the wrist partially flexed, a differential sign may be readily brought to light. In functional contracture of the fingers in flexion, the position of the wrist whether in ex tension or flexion, has but small influence

upon the flexor contracture of the fingers; any effort to alter the position of the fingers by altering the position of the wrist is attended by increase of the flexion of the fingers unless the flexion of the wrist be forced to a point where even forcible voluntary flexion of the fingers is impossible. Therefore, under such circumstances, to overcome flexion of the fingers very forcible and complete passive flexion of the wrist must be made On the contrary, in flexor contracture of the fingers due to an organic nerve-lesion, an alteration of the flexor position of the fingers is immediately related to the passive alteration of the position of the wrist. For example, if, in organic flexor contracture of the fingers, the wrist be passively flexed, there follows simultaneously a proportionate relaxation of the flexor contracture of the fingers; if, on the other hand, the wrist be passively extended, the flexor contracture of the fingers will be proportionately increased (Babinski).

In the study of contractures it must be remembered that no matter whether the cause of the original contracture be functional (hysteric) or organic, if it be maintained long enough fibro-tendonous retractions occur which mechanically fix a limb in a vicious position. Therefore, such fixation is not a demonstration that the original cause was an organic nerve-lesion. In general it may be said that the deformities due to hysteric contracture are much more marked than those due to organic nervous disease if atrophy has not taken place; and, too, that they differ usually in form from those that experience has shown to be characteristic of organic nerve-lesions.

It may be laid down as a law that when a muscle or a group of muscles that cannot be contracted separately by the will-i. e., not without contraction of other muscles normally associated with it in the synergy necessary for certain movements-are paralyzed, the loss of power is due to a nerve-lesion (disease of the muscles concerned being excluded). In other words, there are certain synergic associations of muscles and groups of muscles in movements which cannot be voluntarily dissociated. voluntarily dissociated. Therefore, in case there is loss of power in one or more muscles of a group or groups of muscles known to be thus synergically associated, while the others act in obedience to the will, we know that the paralysis is organic. A few examples will serve to make this point clear.

A patient is unable to close one eye (facial paralysis). When told to close the eyes, that on the sound side closes normally; on the paralyzed side, the eye-ball rolls upward in the orbit, conceals the cornea, and exposes

the sclera alone in the palpebral fissure, the size of which has diminished but slightly or not at all. This is Bell's sign, and it proves that the loss of power to close the eye is due to an organic nerve-lesion; for this dissociation of complete upward movement of the eye-ball without closure of the eye cannot be voluntarily or functionally induced. know without further consideration that there is an organic element in the case.

A patient presents the following conditions: when the right arm is extended horizontally in front of the body, the right scapula springs backward very prominently from the chest wall, in a manner to suggest a wing, while on the other side, in the same movement, the scapula remains close to the chest wall. We know immediately that there is paralysis of the right serratus magnus muscle, due to actual nerve-lesion, because contraction of the muscles that elevate and extend the arm cannot be voluntarily or functionally dissociated from contraction of the serratus magnus.

When the forearm is forcibly flexed on the arm, with prominence of the biceps there is also prominence of the supinator longus which forms the firm, rounded contour of the radial side of the forearın. Absence of the prominence of the supinator longus when the arm is forcibly flexed proves that there is organic paralysis of that muscle, since in this act the contraction of the biceps and supinator cannot be voluntarily dissociated (Babinski). Since the supinator is frequently paralyzed with the extensors of the hand and fingers, the presence of this peculiarity makes it possible to determine the true nature of extensor paralysis of the hand which may be closely imitated by voluntary wrist-drop.

There are also synergic functional associations of corresponding muscles and groups of muscles of the two sides of the body, unilateral disturbances of which have similar diagnostic value. A few examples of such anomalies will emphasize the importance of familiarity with the law of functional synergic association of muscles.

With the neck and chest exposed, a normal subject is made to open the mouth as forcibly and as wide as possible. In this act, if the subject be not too fat, the long fibres of the platysma myoides muscle will be seen to stand out in several lines reaching from the lower jaw to the upper portion of the chest, and effacing or altering the depressions above the clavicle on each side; and these alterations of the lateral contour of the neck will be practically symmetrical and of equal degree. In any event, under normal circumstances, in this act, whether the platysmas contract or not, there is no appreciable differ

ence of contour on the two sides of the neck. On the other hand, when the lines of the platysma stand out markedly on one side, and on the other side they do not appear at all or are but slightly marked, we may conclude with certainty that there is an organic nervelesion that causes the deficiency on one side; for this alteration of bilateral simultaneous activity of the platysmas cannot be voluntarily imitated in the act of forcibly opening the mouth. In order to prevent any misunderstanding, it should be pointed out that unilateral contraction of the platsy ma is possible when the jaws are firmly closed, and that unilateral spasm of this muscle occurs in some cases of spasmodic wry-neck, and therefore it might be imitated voluntarily; but in the presence of such permanent or occasional spasmodio contraction of one platysma, if the other were not paralyzed it would contract when the mouth were forcibly opened.

The phenomenon just described-contracture of the platysma on one side with absence of contraction of the other, is called the sign of the platysma (Babinski). It is often found in organic hemiplegia and unilateral facial palsy-and never in hysterio hemiplegia; hence its importance when present as an aid in differential diagnosis of these common pathologic states.

Another sign due to the acute clinical observations of Babinski, usually, if not always, indicative of organic hemiplegia, is that known as combined flexion of the trunk and thigh. This sign is described by Babinski as follows:

"It is found in the majority of patients. affected with organic hemiplegia when the patient lies horizontally on a hard surface like the floor, with the arms crossed on the chest, and then makes an effort to rise to a sitting position. The thigh on the paralyzed side executes a movement of flexion on the pelvis and the heel leaves the floor slightly. On the opposite side the limb remains immobile or the flexion of the thigh and the elevation of the heel occur later and are very much less marked than on the side affected with paralysis; at the same time the shoulder on the normal side is carried forward."

"The movement of combined flexion of the thigh and trunk naturally implies that the limbs are capable of a certain amount of movement; thus, theoretically, it should be absent when paralysis is complete, and observation confirms this. In fact, generally it is only some time after the beginning of hemiplegia, when the paralysis is somewhat attenuated, that the phenomenon appears. In the earliest phase of hemiplegia, since the lack of power on the paralyzed side is complete, either the patient is so prostrated that he is

not capable of the least effort, or when he tries to assume a sitting posture he makes a movement of rotation around the long axis of the, body toward the paralyzed side; this movement seems to me to be the result of the limited action on one side of the body of the muscles which incline the trunk forward." In contrast with these positive signs of organic nervous disease that form features of paralysis itself, there are others quite as positive which form features of some functional spasms which simulate paralysis. For example, ptosis, or falling of the eye-lid, may be organic or functional; but functional ptosis is in reality spasmodic or due to voluntary contraction of the orbicularis of the eye-lids. Falling of the upper eye-lid if due to organic nervous lesion, when the facial nerve is intact, is always characterized, when the patient makes an effort to elevate the lid, by elevation of the corresponding eyebrow, and even backward inclination of the head, the obvious purpose of which is to uncover the pupil. This is very apparent in double ptosis, and brought out clearly when the weakness is unilateral, by covering the eye of the unaffected side. Here the elevation of the eyebrow at command to try to open the affected eye is practically demonstrative, like Bell's sign of an organic lesion.

On the other hand, unilateral hysteric or pseudo-ptosis presents a very different picture; the partial or complete closure of one eye is accompanied by lowering of the corresponding eyebrow, and the other eye, likewise, shows a slight lowering of the upper lid accompanied by elevation of the corresponding eyebrow. Such a picture is proof that the anomaly is functional (hysteric, voluntary). The truth of this assertion may be readily demonstrated by attention to what takes place when one eye is voluntarily closed and the other is kept open. One may study this act in oneself with a mirror, though better in a normal second person. When one eye is closed and kept closed the eyelid is depressed with contraction of the orbicularis of that eye; the other eye also tends to close, and a forçible effort must be made to keep it open, which results in an initial increase of elevation of the lid which is aided by elevation of the eyebrow. With continuance of this voluntary closure of one eye, the other eye tends more and more to close, and with this the elevation of the corresponding eyebrow is increased to oppose the tendency of the orbicularis to act with its fellow. This fact will be readily apparent to one who be gins to use a microscope with one eye while closing the other; as the monocular work is continued it will be found increasingly difficult to maintain the eye open and the increas

Professor of Pathology and Bacteriology, State University of Iowa, College of Medicine; Director of the Iowa State Board of Health Hygienic Laboratory.

WE have just listened to a discussion of the causes of consumption and the changes which the tissues undergo when affected by this disease process, and we are in a good position to appreciate the importance and the possibility of applying hygienic measures in the stamping out of this disease process. Of all diseases common to man, tuberculosis is the most widespread and the most deadly. Other diseases have at times caused more dismay, more panic and for short periods, even the most constant and most pestilental of wider destruction, but consumption has been them all; the worst scourge of mankind. It has indeed been most properly termed "The Great White Plague." It spares no nation, no age, no vocation, no class of people.

The following figures may serve to emphaject of tuberculosis. size the importance of considering the subIn this country about It is 1,125,500 people have consumption. estimated that the cost of consumption in New York is $1.16 per day per victim. This would mean that consumption is costing the United States $476,325,000 every year and costing the State of Iowa with its 8,000 consumptives, if the recent estimate made by the Board of Control be correct, $3,387,200 every year.

According to our courts, the value of a human life is placed at $5,000. It is estimated that 150,000 people die from consumption in the United States every year. If we consider the rating of our courts as equitable, tuberculosis is costing the United States $750,000,

Read before the second annual meeting of the physicians of the First Councillor District of Iowa at Fairfield, Ïa., January 26, 1906.

000 a year and the State of Iowa $10,000,000 a year. But you say, that the estimate as to the value of a human life is made too highnot too high when the estimate is made on me, but my neighbor isn't worth quite so much. Let us then make a more conservative estimate. The average age at which consumptives die is 35 years. The life expectancy of a man of 35 years of age is 32 years. This means that 4,800,000 years of life are lost in the United States by a single year's consumption death-list. If we figure that an individual is worth $50 a year to a community, the annual loss to the United States from consumption is $240,000,000, and the

the State of Iowa, it is $3,200,000.

How are we to protect ourselves from tuberculosis?

Let us first consider measures to avoid the tubercle bacillus. Of prime importance is the subject of

Sputum and Expectoration. - The sputum of a consumptive, coughed up and expectorated, is probably the cause of more than 95% of all cases of tuberculosis. All of us occasionally take cold and phlegm or sputum gathers in the throat. None of us can be absolutely sure that we do not have tuberculosis. Therefore the only safe rule to adopt for all is to stop spitting and expectorating except into our handkerchiefs, or into vessels provided for that purpose.

None of

us should ever be guilty of spitting in our homes, or in public places, as public buildings, street cars, railway coaches, etc. If we must expectorate, let us use our handkerchief or a spittoon (which should be frequently cleansed). Let us all join the anti-spitting crusade. What has been said about spitting applies of course with double force to consumptives. If there would be no spit there probably would be no, or very little, tuberculosis. Every city should have an antispitting ordinance, unless prechance its citizens lead such ideal lives that such an ordinance is unnecessary. I hear some one saying, How, in this land of the free, do you dare to make suggestions that so curb our liberty? Let us remember, however, that liberty is not license. Liberty has limitations. "A man can say that he has the liberty to swing his arm as far and wide as he pleases. I say, yes, he can swing his arm as far as he pleases, so long as his arm doesn't reach the tip of my nose, or he may find out that the arm of decency and the law can reach the tip of his nose." Yes, a man can expectorate when and where he pleases, so long as he does'nt expectorate where his sputum may injure my health. Sputum should never be swallowed lest it set up a disease in

the stomach or intestines. When coughing, the hand should be held before the mouth. We should turn away from a coughing neighbor.

We should avoid association with tuberculous individuals, especially if they are of an uncleanly disposition. This does not mean that every consumptive should be deserted. The consumptive in himself is not necessarily dangerous. He becomes so only by his habits. If he takes the proper care of his sputum and observes the proper rules of cleanliness, we need have little fear. The dis

regard concerning spitting in the past, has exposed every person to the dangers of consumption. If all are exposed, why is it that some of us become tubercular and others do not? Our body when in perfect health is provided with factors which will keep out disease-producing bacteria, and destroy those which occasionally gain entrance before they produce disease. The fleshy frame of every person is some time or other invaded by germs, but unless the soil is favorable, the seed will not grow nor will the plant thrive. The parable of the sower sets forth in an admirable way the story of the disease. The seeds that fall by the wayside are the bacilli that reach our great highways, the air passages and the intestines, in which they are picked up and devoured by the cells and other agents of the body, representing the birds of the air. The seed that falls on rocky places are the germs that enter the body and pass to the nearest lymph-node by which their activities are checked. They spring up, but having no depth of earth they soon wither away. Those which fall among the thorns are the bacilli which enter the various crgans of the body. The soil is good but the thorns represented by the connective tissue of the system grows up around them and chokes the seed. falling on gcod ground, with conditions favThis represents a curing of the process. But orable to growth, the seed springs up, increases and brings forth fruit, as represented by the sacrifice of human lives, some thirty, some sixty and some a hundred fold. These represent the well marked cases of. tuberculosis. A part of the 13th chapter of St. Matthew, slightly modified. "He that hath ears, let him hear." What may we do to maintain that state of health which will successfully combat the invasion of the germs of consumption, or when entered will remove and destroy them? My answer is, Live up to the best rules of hygiene.

b. We should have plenty of fresh air. Our homes and places of business should be thorougby ventilated. We should spend some time in the open air every day, the longer