active or passive. Pain is in the same distribution as Type I, and in severe cases it may resemble a bracial neuritis.

Type III. The chronic type; the essential characteristics are painful motion, but the full arc exists. The trouble is due in this class to slight irregularities of contour of the base of the bursa usually external to the bicipital groove. Motion, instead of being smooth, is jerky and interrupted in its arc. Localized tenderness may or may not be present. If present, then Dawburn's sign is present. Abduction and external rotation are but slightly interfered with, but at some point in abduction acute tenderness is experienced, which disappears as soon as the tuberosity is under the acromion. The scapula does not accompany the humerus. There may or may not be pain, and if present it is often felt at the insertion of the deltoid.

Dr. Stevens states that he has found two cases out of seven that could not be placed under these classifications. There seems to be a class of cases which are usually the result of trauma, the symptoms of which are practically those of subacromial bursitis, and which may be, and perhaps always are, accompanied by some inflammatory changes of the bursa, but which show distinctive symptoms sufficient to call attention to the involvement of the short rotators, the action of which Codman does not take up in his article.

There is also a class of fractures involving the greater tuberosity of the humerus, not so rare as has been assumed, which invariably lead to a set of symptoms resembling bursitis. Some of these classes undoubtedly develop a bursitis, and to that condition their symptoms should direct attention.

Subcutaneous Rupture of the Kidney.

G. V. Finlay (Pester Med.-Chir. Presse, April 11, 1909) describes a case of subcutaneous rupture of the kidney successfully treated by extirpation in the Stephanie Children's Hospital. The patient was a child. three years of age who had been run over, and was brought in unconscious. She was blanched, the temperature was 36.0° C., pulse scarcely perceptible, 170 to 180 per minute. In the right hypochondrium and lumbar region was a suffusion a handbreadth in size. In the right hypochondrium was a diffuse resistance moderately sensitive to pressure. After the use of stimulants consciousness returned and the pulse became stronger. After some hours the patient passed on urination almost pure blood. In the evening she was weaker and repeated caffeine injections were required. During the night there was painful bladder tenesmus and almost pure blood was several times passed. In the morning the urine was pure blood, the abdominal muscles were somewhat tense on the right side, especially in the kidney region, which was sensitive to pressure and a resistance the size of a fist could be felt in the lumbar region; near this resistance signs of an abdominal effusion were present. The diagnosis was of rupture of the kidney complicated by extraperitioneal and intraperitoneal hemorrhage, and this was confirmed at the operation. The kidney was found to be torn across, while on the perineal tissue was suffused blood and clots. The upper and smaller part of the kidney was anemic and divided from the lower half, which was still partially in communication with the hilus vessels. Strong bleeding in the neighborhood

of the hilus started as the coagula were cleared away from between the two parts of the kidney, and the vessels were ligatured and the kidney removed. On raising the right lobe of the liver a tear was found on its under surface which extended into the peritoneum. The peritoneal opening was widened and the intraperitoneal effusion emptied, and the peritoneal wound stitched and drained; the liver wound was plugged. The patient was able to leave the hospital, recovered, after seventeen days. In discussing the symptoms and diagnosis v. Finlay points out that while hematuria is in 95% of the cases the symptom by which injury to the kidney is diagnosed, the presence and rate of appearance of the perirenal hematoma gives a measure of the grade of the injury. Repeated examinations should be made in any case of suspected injury to the kidney, and these should continue over a considerable time, lest late infection of a small hematoma should be overlooked. Treatment depends on the grade of the injury. In no case should the kidney be removed unless the injury has altogether destroyed its function.

Basophile Granules in Red Cells.

In anemias of man and in those of animals produced experimentally there are to be seen red cells containing granules which stain by the aniline basic dyes (methylene blue, etc.). These granules are irregularly rounded in form, are variable in size, and are often situated at the thick peripheral part of the red blood corpuscle (Jolly, Archives des maladies du coeur, des vaisseaux, et du sang, May, 1908). From nuclei of red cells, such as are to be found in the blood of severe forms of anemia, these granulations are easily distinguished by the fact that they are multiple, they have no special affinity for nuclear stains, and they do not show a vacuolated appearance, as the nuclei found in red cells may do. These basophile granulations of the red cells have been found in the majority of the anemias, but in varying frequency; for example, in chlorosis they are rarely found, while in lead poisoning they are almost constantly found. Sabrazès showed that by the injection of a solution of lead acetate into the peritoneal cavity of a guinea-pig basophile granulations could be made to appear in the red blood cells. As to the significance of these basophile granulations: Askanazy and Sabrazès considered the granules to be the result of the fragmentation of the nuclei of nucleated red cells; the staining properties of the granules, however, are different from those of the red cell nuclei, and these facts do not support these authors' conclusions. Further, if these granules were the result of nuclei fragmenting, one ought to find them rare when the nucleus is large, and very numerous when it is small and atrophied; such, however, is not the case. Another argument against the nuclear origin of these granules is the fact that they are not found in all cases of blood regeneration, and they are very rarely found in the bone marrow. Grawitz, Bloch, Pappenheim, etc., consider these granules to be due to some alteration of the red cell; Askanazy thinks that cells containing these granules are young red cells. From his own observations and from the evidence obtained from the work of other investigators the author is inclined to think that polychromatophilia, granular red cells (which are to be seen in unfixed blood films), and basophile granulations in the red cells are only different degrees of the same alteration of the corpuscle, alterations which are probably due to a hydration of the stroma or corpuscular membrane.

Spastic Paraplegia Dating From Childhood (Little's Disease?), With Little or no Demonstrable Lesion in the Pyramidal Tracts. John H. W. Rhein (The American Journal of the Medical Sciences, December, 1908) calls attention to the remarkable and interesting fact that spastic paraplegia may occur with little or no demonstrable degeneration in the pyramidal tracts of the cord. Although in some cases degeneration of the pyramidal tracts has been described, this has been caused either by a spinal lesion, a meningo-encephalitis, a sclerosis of the motor cortical areas, or a venous effusion into the meninges, causing destruction of the cortex. The cases of porencephalon and atrophy of the motor and other convolutions without degeneration in the pyramidal tracts present a different problem; and yet more difficult of explanation are those cases in which there is little or no demonstrable lesion, either in cortex or the motor tracts of the spinal cord.

In some cases no true degeneration of the pyramidal tracts is found and in these have been described: A fineness of the fibers of the pyramidal tracts, a scarcity of fibers, incomplete myelization without diminution in the number or size of the fibers, agenesia or imperfect development of the pyramidal tracts, or atrophy of the pyramidal tracts. while an effort has been made to connect some of these conditions with degeneration of the cortical ganglion cells or diminished number or absence of these.

It is not difficult to understand that sparseness of fibers or fineness of fibers may have the effect of lowering conductibility, and in this way interfere with inhibitory control normally exercised by the cortex over the spinal centers, the persistent action of the cell of the anterior horns thus giving rise to spastic conditions of the extremities.

The cause of the agenesia of the pyramidal tracts, the presence of poorly developed thin fibers, and the sparseness of fibers in the pyramidal tracts result from a lack of the usual number of cortical ganglion cells is plausible, although extremely difficult to demonstrate satisfactorily. Spasticity is due to arrest of growth of the fibers in the pyramidal tracts, that the axis cylinders are absent in the cord, but present above the anterior pyramids.

How can the spasticity be explained when the pyramidal tracts are not degenerated? The presence of fibers in the pyramidal tract presupposes the presence of intact cells in the cortex or at least in the cerebrum. The character of the fibers and cells, then, must have some bearing upon the development of this symptom. When fibers of small caliber are called upon to conduct vigorous motor impulses do we not meet with the same condition as when large currents of electricity are forced through wires of small caliber, that is, increased resistance and imperfect conduction? The increased resistance offered by the small fibers to the motor impulses may prevent the impulses from reaching the cells in the spinal cord entirely and thereby there is a cutting off, partial at least, of the influence of the higher inhibitory cortical centers. While, of course, this cannot be demonstrated, it seems possible explanation of spasticity in some cases.

It is very extraordinary, but people can live to be real old and suffer the greater part of their life from spastic paraplegia without its being possible to demonstrate more pathological change in the nervous system than a slight or perhaps indefinite one.

CONTEMPORANEOUS EDITORIALS.

A Wave of Occultism.

Western civilization (The Lancet-Clinic, August 28, 1909) seems to be at present in danger of being engulfed by a wave of occultism. The same intellectual tendencies that at one time turned Western Europe into a veritable madhouse are at work. The whole business started as long ago as 1847 with the rappings of the Fox sisters at Rochester, N. Y. Since then it has spread slowly and insidiously over Europe and America. Spiritism is not the only form it takes. It is expressed in the mental-healing cults and in a dozen and one frothy philosophies of optimism. It is seen reductio ad absurdum in the Eddy sect which reaches the limit in spiritualizing everything away to nothing.

From below the foci of infection are dingy black parlors where vulgar mediums coin the credulity of feeble-minded old ladies and gentlemen into the cash of the realm. From above in this country, as Dr. Witmer, of the University of Pennsylvania, has pointed out (The Psychological Clinic), encouragement is tendered and a philosophical and academical dressing given these tendencies by the psychological department of Harvard University. As the pedigree of modern occultism may on its vulgar side be traced to the Fox sisters, on the side of academic mysticism it reverts directly to that great charlatan of philosophy and arch obscurantist, Hegel. The union of the two branches was consummated when we were treated to the spectacle of Prof. William James investigating Mrs. Piper. In their ideas of mind and spirit, in their pet hypothesis of telepathy, the occultists in very truth out-materialize the crudest of the materialists. Yet they are always crying out that they have given the death blow to materialism. Well, if materialism is dead then modern occultism is its ghost; and judging from the quantity of recent literature on the occult it is not preserving the usual ghostly silence, but is emitting an incoherent gibber.

Since hysteria is simply an artificial somnolence (akin if it is not identical with the hypnotic trance and suggestible states which arise from it) of the whole personality or a disassociation with resulting somnolence of a section of it, the treatment of any individual hysterical resolves itself into the problem of waking the patient.

Therefore, when we find a large number of people going about with a fixed smile and a fixed idea that all that is is spirit and all that is not is but mortal mind; when we find men deserving respect in their own fields, such as Flammarion the astronomer, gravely discussing why ghosts wear clothes; Crookes, the physicist, naively announcing that during many months he was in daily communication with the incarnate spirit of a young woman whose temperature he took and to whose heart he listened; William T. Stead amusing himself with automatic writing, or A. R. Wallace denying the truth of the confession and explanation of the very medium who deceived him—when we contemplate these cases we are forced to conclude that many of these individuals must be, in a sense, hystericals, sleep walkers, their consciousness more or less disassociated, and that the only way to cure them would be to wake them up.

This seems to be the effect upon many of the pursuit of the occult, and herein lies its great danger. Unrestrained it will eventually turn us into a

nation of neuropaths and hystericals; already neurologists are finding many of their cases complicated with the Eddyism and spiritism symptomcomplex ("Clinical Observation of Psychoses Presenting the Eddy Cult as a Complication," Dewey, Chicago Neurological Society Transactions, October 22, 1908).

It is the duty of every man who has the welfare of science, medical or general, at heart to oppose all along the line this onset of the occultists and obscurantists, because even a tentative triumph by them would tend to destroy the standards of reality from which scientific departures are made. They should be combated by every one who feels any interest in maintaining the influence of real religion, because the effect of such tendencies has been in all stages of the world, from the times of the witch of Endor down to the present day, the corrupting of religion with the most degrading superstition. From the purveyors of the "cheer up" philosophies to the spiritists themselves one and all should be regarded with grave suspicion by any man or woman devoted to the cause of any phase of social reform, because their effect can only be detracting of attention from the real to the unreal, from the important to the futile.

The Orderly.

What interne or nurse, what superintendent or other hospital official, does not have pictures, pathetic or ridiculous, evoked by the word "orderly?" Perhaps the term does not appeal to all those who have had a "hospital experience," for the person who, in the male wards, acts in the capacity of minister unto the needs of the patients, is sometimes given the dignified name of "ward master." Perhaps this latter term is more fitting. in that it expresses the extensiveness of his official domain and the authority which he may exercise. Though nominally supposed to be a minister unto a score or so of men, he, like some other servants, has those whom he would serve under his very thumb, for they are a bed-ridden company and he is (usually) able to be about and upright on his pins. Master, indeed, he is, and those he waits upon must often bide his time until he finds it convenient to bring the much-craved glass of water, or serve some more pressing bodily need.

But the name "orderly!" There is humor in it, and was it applied for that reason? Perhaps a "d. t." may occasionally need to be squelched, or a subject of recent amputation, noisy in his dreams about a missing member, may have to be poked in the ribs, but otherwise a company of sick are usually fairly law abiding, even though of the male persuasion. As for the subject of this sketch, is he himself always orderly? We remember that an interne was making rounds early one morning with a German physician. They were leaving a ward on the third floor, and were approaching the stairs, when they heard a scuffling below as of many feet, and there, sprawled upon the landing at the top, a heap of humanity evidently much overcome by his climb. It was one of those ward helpers on his way to his sleeping quarters in the attic. "What iss dat?" the chief exclaimed, throwing up his hands in astonishment. "Oh," replied the interne, "that's one of the night orderlies just turning in." "Hah!" exclaimed the doctor. "He iss not orderly, I call him positiv' disorderly!" We recall one of these men who, when off duty, spent his time reading the masterpieces of literature. He would come into my room and quote