the sigmoid are elongated sigmoid located in the proximal abdomen and possessing a narrow foot accompanied by mesosigmoiditis due to vigorous action of the left psoas muscle which traumatizes the sigmoid inducing migration of germs or their products through mucosa, muscularis into the serosa, inciting plastic peritonitis in 80% of adults. autopsies. The foot of this giant verticle sigmoid is narrow and by the contracting mesosigmoiditis results in a narrow style around which may rotate the sigmoid loop. This was the condition I found in physiologic volvulus which occurred in perhaps 2% to 3%. [To be continued.] THE RELATION OF MAN TO NATURE (A ALBERT S. ASHMEAD, M. D. NEW YORK, The plastic peritonitis in general ends in two methods, viz: 1. The most frequent, the plastic sigmoiditis binds the left surface of the mesosigmoid to the ventral surface of the psoas muscle. Such subjects cannot have sigmoid volvulus from mechanical condition. 2. The second state of the mesosigmoid arising from the mesosigmoiditis is a progressive shortening, a contraction of the base of the mesosigmoid, that is the base of the mesosigmoid becomes a very narrow pedicle from the progressing, contracting mesosigmoiditis, so that peristalsis cf the sigmoid induces a rotation of torsion of its base. In autop-fornia, who, setting aside a well-known verse sies I have found partial rotation of the mesosigmoid, especially during the existence of mesosigmoiditis-as far as 180 to 360 degrees. Sigmoid volvulus is due to the torsion, rotation, of the narrow pedicle of a mesusigmoid contracted at its foot by mesosigmoiditis. When one untwists, detorsionizes the volvulus and releases it, the sigmoid flies, rotates, like a spring into its original volvulitic condition. To prevent the volvulus from returning to its original torsion in dogs I sutured it in situ resection may be required to overcome the acute torsion. Most subjects have ample time to acquire sigmoid volvulus, as they are generally over 40 years of age. There is frequently physiologic sigmoid volvulus in autopsy which is partial torsion. of the mesosigmoid, however, obstruction is incomplete. The marked tympanites of sigmoid volvulus is at first localized in the left iilac fossa-a slight diagnostic point of the sigmoid is the most varied of any segment of the colon in loctaion and capacity of its lumen. The tympanitis may be located in the right abdomen while the non-tymphatic loop may be forced around the constricted foot of the volvulitic sigmoid. Childhood is not predisposed to sigmoid volvulus, notwithstanding the relatively elongated sigmoid and mesosigmoid, because the angle of mesosigmoid insertion (what I term von Samson's angle) is located well proximal ward on the lumbar vertebra. Why woman is practically free from sigmoid volvulus I am, so far, unable to explain. Sigmoid volvulus occurs practically in men possesssing what I term the "giant verticle sigmoid" which are located in the proximal abdomen and occurred in perhaps 15% of the FIFTEENTH PAPER. * Lu There is no thoroughfare to science. ther Burbank, the vegetable wizard of Cali of scripture, has induced nature to reproduce according to his will instead of each species after its own kind, is announced as a convert of the new doctrine of eugenics. This doctrine-by the way, a very old one dressed in a new name-relates to the bettering of the human species by more careful breeding and child culture. Mr. Burbank speaks of children as "the most precious and pliable product of the ages, "and says what "the scientific breeder is called upon to do is to inaugurate a system of selective weeding." The spirit of old Lycurgus, if it keeps in touch with affairs, must invisibly applaud the vindication, in the name of modern science, given to the principle of the "weeding" out methods which he introduced on the Spartan hillsides. But it may be doubted whether Mr. Burbank will be as successful in eugenics as in plant transformation. It may be true that better bodies may be secured for the remainder by removing the deficient. It may also be true that brain lobes can be developed as the cattle-breeders have developed loins in short. horn cattle. But if there is to be weeding it will always be some one else's darling, not our own, which must feel the scythe of the aberuncator. Like Artemus Ward, who was willing that his wife's relatives should be sent to the war, we would confine the scheme to other people's children. For our own we propose to preserve with small regard to the effect on the species. Moreover, for such is one of the most abiding mysteries, the more they are crooked and lack, the more we cherish. Survival of the fittest may be the ruthless law of nature, but *The first paper of this series appeared in the MEDICAL FORTNIGHTLY issue of April 25, 1905. human nature seeks to repeal it; moved by an instinct which is in the very fibre of being it seeks to secure the survival of the unfittest. Mr. Burbank should confine himself to his plants and flowers-to the solution of such problems as he is capable of solving. Science, although she is a most valuable servitor, and has given many suggestions which are helpful, is not to be made sole guardian of the children. Perhaps her way would be the best one, but she will not be allowed to try it. An Indian fable tells how Glooskop, the hero god, after conquering all his enemies, rashly tried his hand at managing a certain baby, Wasis by name, and soundly punished for his rashness. There never has been an exact science of child nurture, and probably never will be. There are some things past finding out-some truths that are not respected even when found out. The child may be a Poor stumbler on the rocky coast of woe, was Nevertheless, stumbling parents will continue to help the stumbler according to the good old hit-or-miss plan, no matter what the din of the eugenics. "The Greeks were impressed, as all peoples and generations have been, with the mutations of fortune the vicissitudes of human life. Their observations and experience had taught them that long continued good fortune and unusual prosperity often issue at last in sudden and overwhelming calamity" (Myers Ancient History, Ed. 1904, p. 137). Thus was acknowledged long, long ago, from a period almost wholly pre-historic, the great principle of nature the law of demolition, Mr. Burbank, the creator of his flowers and plants and vegetables, the products of his intelligence, gives them his watchful solicitude during their lives; he forgets and neglects them not. He preserves them from enemies in the soil and in the air; and sees to it that he introduces no noxious element; he seeks to know their needs, and their needs to supply. He endeavors to make their world favorable to their highest development to their e-volution, their progression. To that Eden, no serpent or weed is allowed entrance to corrupt, to destroy; but, rather, is beauty, and strength and charm, and value conserved. Nor in that abode is to be found any voluntariness to which evil can address itselffor is not its creator on guard to keep evil out rather than to introduce evil and lurk in the bushes to watch the overthrowing work? This fungiferous Sparta is not expected to go out to war, to be contaminated by the world at large; and, likewise, it is so pro tected that the passes on its surrounding walls are defended in its behalf. Why this admirable condition in this little world? Because its god is solicitous for the welfare of its individuals. Let not the captious critic here hasten to say that its god cuts and slices, and stings and transfers, and takes away, and adds and lops off and binds on; the dwellers feel no pain. In the Sparta of old it was the body alone that was cultivated as in this vegetal Sparta it is the body that is cultivated-for in this Sparta there is no mind, all is plasticity of matter subject to the formative intent of its creator, and his moulding hand. Here the metaphor ends. The Sparta of old passed away; the animal Sparta; the warring Sparta: the merciless Sparta; the hideous Sparta; the Sparta devoid of tenderness; the Spartan mother who said: "Go, return with your shield-or upon it;" the child bred as an animal. In that Sparta the mind was not permitted to grow; it was not recognized except as a power to move the body in the interest of the whole state as a war body. Is it seriously to be contemplated that human effort can avail against the great law of Nature that will at last reduce to mere memory the vegetal Sparta at Los Angeles? Can man, a mere growth incidental on the shores of time say to himself, for himself, I will, or I will not! No! He is as much a product as are the products of the field; and his special cultivation here and there by his individual self appointed teachers and educers cannot specialize him as an exception to the great law of change; he must go when and whither he is driven. He is here to suffer; he cannot escape. "Man is a shaken reed in which the soul, that air, doth ever rustle and repine' (Omar). His epitaph may be "He would have been better, if his creator had permitted. able to lie back in the chair. Previously her health had been good except for occasional headaches. She is mother of six children. She had been well at bedtime and the dyspnea came on abruptly at 10 p.m. The pusle was intermittent and labored, 60 per minute. On auscultation, I found loud blowing from fourth to sixth intercostal space. The heart was laboring so intensely that lifting was plainly seen through chest wall. There were no valvular murmurs, but a very distinct churning sound, and many coarse rales over the left lung. I gave thirty minims of ergot, hypodermically, followed by twenty-five minims of adrenalin chloride, 1:1000 (P.D & Co.) as soon as it could be obtained. This dose was repeated in thirty minutes. Patient began to be relieved in thirty minutes. In two hours In two hours she could lie down. At 10 a. m., on June 6th, she was quite comfortable. Adrenalin was continued in ten minims doses per os for three days, followed by eight grains of potassium iodide every three hours, until the clot was absorbed. The lifting of the chest wall gradually subsided and at end of a month the heart action was normal. This was evidently a case of rupture of a branch of the coronary artery, and the interesting points about it are its abrupt beginning, the patient's previous good health, the sudden increase in bronchial secretion and the prompt subsidence of the symptoms after the administration of adrenalin. After six months of good health, the patient became excited about a fire occurring in town, and the former symptoms recurred. I was away from town and did not see her until one hour after the beginning of the attack. There was more bronchial secretion than in the first attack, at least one pint. The finger nails and lips were cyanotic, skin clammy and there was extreme dyspnea. The heart action was very labored. The physician who had been called in my absence administered 1-65 grain of atropine sulphate and sixty minims of adrenalin chloride, 1:1000, by the mouth. I at once administered twenty-five minims of the adrenalin hypodermically and repeated the dose in twenty minutes. Patient began to feel relieved in fifteen minutes. Cyanosis had disappeared in an hour. In two hours she was able to lie down. The bronchial secretion and rales were absent the following morning. The same treatment as in the previous case was followed, except that fluid extract cactus grandiflora was given for ten days. In this second attack the action of adrenalin was positive. In the first one it was not possible to draw conclusions because ergot had been administered. Adrenalin by the mouth failed to give results, but relief was immediate after preparation was administered hypodermically. It is now three weeks since the attack and the patient is doing well. The clot is nearly absorbed. February 15th, 1906.-Patient remains in good health. Heart action normal. Clot entirely absorbed, judging from absence of any murmurs and lifting of chest wall. There is no question in my mind as to the presence of pulmonary edema in this case, and I am not cognizant of anything in my report to lead any one to think otherwise. Furthermore, pulmonary edema is not, as a rule, classed as a distinct disease, but rather as a condition secondary to some preexisting pathologic condition. It is more in the nature of a symptom than a distinct entity. The point in favor of my diagnosis and against that of pulmonary edema, except as a secondary condition to the real causative pathological condition to the lesion, are: Etiology (Butler).-Most commonly associated with pneumonia, cachexia carcinoma, grave fatal anemias, acute and chronic nephritis, acute fevers with heart weakness, cardia valvular disease, cerebral apoplexy or injuries. Osler, Strumpel, Thompson, etc., give these same causes and add no more to them. Physical Signs.-Impaired resonance, or slight dullness over the base, with absent or weak, perhaps broncho-vesicular breath sounds. There are abundant large and small rales of an unusually liquid character over involved areas. Symptoms. -Increased dyspnea, cyanosis, cough and an abundant frothy, watery, rarely tenaceous expectoration, which may be bloodstained if congestion is present; fever absent unless due to febrile condition. The symptoms and physical signs were as above described in the case reported, except that the sputum was not blood-stained. The points which might easily have been misinterpreted were: The absence of any valvular heart lesion, dilatation or hypertrophy; the labored action of the heart not rapid; the churning sound, as if the heart were laboring in a thick fluid; the lifting of the chest wall from the third to the sixth intercostal space, with no marked dispacement of the heart, with no evidence of contraction of the lung, the continued lifting of the heart after edema was entirely relieved and expectoration had ceased. only conditions that would have caused the lifting of the chest wall besides the condition diagnosed by me would be hypertrophy, dilatation or dilatation of the ventrioles. The Not one of these conditions named could have been present without displacement of the heart or signs of dilatation or hypertrophy, none of which has ever been present in this case, and she is at present doing the house-work for her family of four persons. As to whether my diagnosis of rupture of the coronary artery was correct, since the question has been raised whether the case could not be more properly called one of pulmonary edema, I wish to cite a second case in which the symptomatology very nearly duplicated this case, but which did not recover and the exact pathology was disclosed by a post-mortem examination, which. was fortunately obtained. Patient, aged thirty months, had had a mild attack of spasmodic croup three days previous. I was called in haste at 7:30 a.m. Found patient cyanosed, breathing with great difficulty, coughing, but not a characteristic croup cough. Pulse 110. Temperature not taken. Parents thought it an attack of croup. I saw that a croupous condition was present, but that it was not true croup; that heart action was too labored, chest wall was lifting, no murmurs, many coarse rales and bronchial blowing sound. Child acted as though there were some obstruction of the large bronchi. The parents assured me that the child could not have gotten any foreign body into the lung. I told them the child could not live. He became more cyanosed, covered with clammy sweat, respiration became more difficult, cough more harsh, heart action became still more labored, and death ensued in one and one-half hours. The parents seemed dissatisfied. I told them, "This was an unusual condition, and that if I had made a mistake I wanted to know it and so did they. Allow me to hold a post-mortem.' They consented. Result: Pericardium distended with blood until the left lung was contracted from the pressure to one-fourth its normal size. Coronary artery ruptured. I had no adrenalin with me. In fact, thought the case one of pulmonary edema, but could not satisfy myself as to etiology. The symptoms in this case were the same as in the first case reported, except that the cough was more aggravated, and of a croupous character. I believe both these cases to be the same in pathology, except that a small branch only was ruptured in the case reported, while a large one was ruptured in the case lost. I don't know whether I could have saved the second if I had made a proper diagnosis and used adrenalin. In closing, it may be of interest to cite a very severe case of edema of the glottis and vocal cords, which was promptly relieved by the hypodermic administration of twenty minims of adrenalin, followed by ten minims administered by mouth every three hours, allowing it to pass slowly into the throat. Patient was unable to swallow anything and nearly strangled to death. Next morning could drink milk with comparative comfort. Patient six months pregnant. This illustrates the power of adrenalin to relieve edema as well as to control hemorrhage. May 23, 1906.-Examination of Mrs. J. L. today shows perfect valvular action. Heart beating 78 per minute. Very slight lifting impulse. Apex beat one and one-half inch from nipple toward median line. Scarcely perceptible hypertrophy of left side of heart. Patient in good health. Has not even had headache for some time. UNILATERAL ASCENDING CHAS. K. MILLS, M. D. PHILADELPHIA. In 1900 Dr. Mills first called attention to unilateral ascending paralysis or progressively ascending hemiplegia as a new clinical type. Several cases have been recorded by him, and others by Spiller, Potts, Patrick and Newmark. The clinical picture in these cases is that of a paralysis beginning in the leg and gradually extending to the arm of the same side; the face in some instances becomes involved, and in some the paralysis passes to the leg of the other side, giving a triplegia. The disease in typical cases, according to the suggestion of Dr. Mills, which was confirmed in one case by necropsy and microscopical examination, is due essentially to primary degeneration of the crossed and direct pyramidal tracts, although other forms. of degeneration may enter or be added. Attention has also been called by Dr. Mills to the fact that the progressively developing paralysis might take a descending instead of an ascending form, although the latter was more common than the former. He was able, through the courtesy of Dr. William Pickett, to present to the Philadelphia County Medical Society an interesting case of unilateral descending paralysis, the case having been recognized by Dr. Pickett as belonging to the type described by Dr. Mills. The paralysis first attacked the left upper extremity, gradually becoming more. pronounced. It became noticeable in the * Abstract of a communication presented to the Philadelphia County Medical Society, May 23, 1906. lower extremity about a year after its inception. At the time of examination this paralysis was marked in the upper as well as in the lower extremity, and was more pronounced in the distal than in the proximal portions of the limbs. The reflexes were all exaggerated on the affected side, a typical Babinski response being present. The paralyzed limbs exhibited very moderate wasting. The face and head were not involved. DOSES: "MAXIMA AND MINIMA." J. R. LANDERS, M. D. BERNADOTTE, ILL. IN acquiring desirably adequate knowledge of remedies and their utility, and establishing a dependable therapy, and at every step in improvement and reliable. progress we meet many problems in "maxima and minima" and a trustworthy advancement, or any advancement, demands their solution-personal solution. The first question with the patient is how he can get the greatest relief in the shortest time at the least expense. The first problem for the physician to solve is what remedy will cure the patient in the shortest time at least expense. When the remedy has When the remedy has been decided on the next question is, what preparation of that remedy is most desirable and of utility competent to the needs and demands in greatest measure-give quickest relief in shortest time at least expense and with greatest certainty? To answer this personally satisfactory we must give study to the different preparations, honestly investigate and find which have most favorable qualities, least unfavorable to determine which deserves our preference. Personal knowledge is essential to confi. dent understanding and application. Simple half possession or understanding is oppressive till digested. It needs the solvent action of personal thought to render assimilable and of individual utility. We must transfer the thought, feeling, opinion or conviction to ourselves and thoroughly digest before we are capable of separating and differentiating fact and fancy, truth and error. Until we have done all this and weighed carefully we are not entitled to an opinion, or rather conclusion. Knowledge and honest conviction must be properly derived. We cannot stand afar off and without reasoning or giving personal thought cry "contrary to theory or hypothesis" and "conservatism." This is but "impression" and not from settled judgment. There are questions to answer and problems . to solve, and they require personal thought and settled judgment. Conservatism does and has neither. We have no record of "conservatism" ever making an invention, discovery or amendment, a progressive observation, or even saving a life. Conservatism would still think it well enough to get the least possible with greatest possible amount with greatest possible expense. Therapeutic betterment and progress mean directly the opposite. The alkaloid and active principle solve many problems in "maxima and minima." They give us the greatest possible effect in the shortest possible time with least possible material at least possible expense; the greatest number of remedies in greatest quantities to meet the greatest emergencies with least delay with least inconvenience, occupying least space (a pocket case), consequently the physician carrying them is best armed, and most often competently armed. We might multiply indefinitely, but this is sufficient to evidence that the active principles are pre-eminently desirable and useful above any and all preparations of which we have any knowledge, personal, hearsay, rumored or reported. represent the ability of greatest effect with greatest certainty at least expense, least inconvenience, delay and most pleasant. They possess the desirable in greatest measure. No valid or effectual weapon in the form of objection or argument has been raised against them. They Such arquebuses as "dangerous" and that "the alkaolid or active principle does not represent the whole plant" are obsolete, inoperative, impertinent, if ever otherwise. And the statement that "the more rational and scientific method is using the entire plant" must be put down as due to ataxophemia, for certainly no one means to claim that guess work uncertainty is more "scientific and rational" than accuracy. In commercialism only is objection founded manufacturers who aim at highest standard and whose goods have proven most reliable have not decried active principles to our knowledge. Pharmacologists of highest attainments, the most trustworthy leaders and teachers. say, "The alkaloids are unquestionably the most important, etc. Who can fathom the benthal depths of galenic uncertainty, and to which depths the physician who uses them may at any moment be plunged. Surely we should get as far away from faults, defects and inaccuracy as possible. Surely we should not tolerate an element of uncertainty if possible to eliminate it. The active principle preparations represent those from which uncertainty has been eliminated in the greatest |