PELLAGRA.* THE wide prevalence of pellagra in the United States makes the appearance of this translation particularly opportune. The original is largely based on Professor Lombroso's earlier monograph on pellagra and it emphasizes Lombroso's opinion that the use of corn is the chief and possibly the only factor in causing this disease. The translators have given us a very readable text and they have added numerous illustrations from various sources. Their many additions and annotations have greatly increased the value of the book; and especially so since these tend to round out the otherwise one-sided views of the original. The book is closed with an extensive bibliography, with copies of the Italian laws against pellagra, and with tables of the corn production in the United States. It can be thoroughly recommended to those who desire expert guidance in this subject. A. W. H. *By Doctor A. Marie, Paris, France. With introductory notes by Professor Lombroso. Authorized translation from the French by C. H. Lapinder, M. D., and J. W. Babcock, M. D. With additions, illustrations, bibliography and appendices. The State Company, Publishers, Columbia, South Carolina, 1910. A TEXTBOOK ON MEDICINE-FOR STUDENTS AND PRACTITIONERS.* THE seventeen German editions through which Professor Strumpell's book has passed testifies to its popularity in its mother country. It is a pleasure to note the appearance of a new American edition under the editorial supervision of Doctors H. F. Vickery and P. C. Knapp. As compared with other textbooks on medicine, Doctor Strümpell's is especially strong on the diseases of the nervous system, which take up about twofifths of the text. An additional chapter on mental diseases following the classification of Krapelin, and written by one of the American editors, emphasizes this feature of the work. Altogether it is one of our best textbooks on internal medicine. A. W. H. *By Doctor Adolf von Strümpell, Professor of Special Pathology and Therapeutics at the University of Leipsic. Fourth American edition. Translated by permission from the seventeenth revised German edition. With editorial notes, additional chapters, and a section on mental diseases by Herman F. Vickery and Philip Coombs Knapp. With six plates and two hundred and twenty-four illustrations. in the text. Volume I. New York and London: D. Appleton & Company, 1911. NUTRITION AND DIETETICS.* THIS elementary volume is intended as a textbook for nurses and medical students. It accordingly contains several chapters on the physiology of digestion and nutrition, which are of necessity brief and, from the viewpoint of the physician, inadequate. A similar criticism applies to the remainder of the subject matter. The chapters on infant feeding are more complete and fully up to date. The presentation is clear and concise and the arrangement excellent. V. Z. *By Winfield S. Hall, Ph. D., M. D. Pages, 298. D. Appleton & Company, New York. SYMPOSIUM ON ANTERIOR POLIOMYELITIS* LANTERN-slide demONSTRATION OF THE HISTOPATHOLOGY OF ANTERIOR POLIOMYELITIS. ALBERT M. BARRETT, M. D. ANN ARBOR, MICHIGAN. THE preparations I show you upon the screen are from various specimens of human cords and from several cords of monkeys in which the disease has been experimentally produced at the Rockefeller Institute. In all of the preparations from the acute cases, changes are present in the meninges, in the blood-vessels, and in the cord substance. The process. occurring in the pia mater is an infiltration of its space with cells which are chiefly small mononuclear forms. This infiltration is most intense in the inner layer of the pia and along the anterior surface and fissure. Less commonly the process may involve the membrane around the entire circumference of the cord. These changes may occur in any region of the cord but are usually most marked in the lower levels. The infiltration extends from the pia mater along the vessels into the cord substance. This extension is best seen around the anterior fissure and central artery of the cord. The process affecting the peripheral arteries of the cord is far less. intense. In and about the walls of the involved vessels are collections of cells. These are of the same type as are present in the pia. They lie chiefly in the adventitial lymph spaces but where the process is particularly intense. they may be present in the perivascular spaces. In the cord itself there are changes in both gray and white substance. These are more extensive and constant in the gray and especially its anterior horns. The changes in the cord occur in relation to those of the vessels. There occur, chiefly in the gray substance, focal collections of cells, apparently *Held before the Clinical Society of the University of Michigan, March 29, 1911. extensions from the infiltrations around the blood-vessels. The bloodvessels themselves show the same infiltration as the pia. Not infrequently there occur small hemorrhages. Apart from this the cord substance shows changes resembling the edema and necrosis seen in myelitis. Where the changes are best marked the nerve cells show varying degrees of degeneration, many having gone on to complete disintegration and disappearance. The cells present in the altered gray substance are largely small mononuclear forms, but in addition there are found large mononuclear types, epithelioid cells, plasma cells and polynuclear leukocytes. The leukocytes seem to be more abundant in those places where the disturbance is most intense. In and around these collections are degenerated nerve elements, many of which give the reactions of fat. Often there are phagocytes, loaded with fat-reacting inclusions. The nerve cells are usually affected in groups corresponding anatomically to the various vascular arrangements. The neuroglia cells show evidences, even in the acute cases, of progressive reaction changes. In the white substance the changes are those of edema, perivascular infiltrations, hemorrhage, and necrosis. In preparations from cords in which the acute process has subsided and the changes present are of a reparative nature, the meningeal infiltration has usually disappeared. The neuroglia elements have undergone proliferative changes. The nerve cells are lessened in number and through the involved parts are found epithelioid cells with inclusions. The infiltration of the vessel wall has changed; lymphocytes are rare and there are present epithelioid cells with inclusions. In preparations from cases which have reached the chronic, resting stage, the evidences of the former acute process are seen in the atrophic condition of the horns and disappearance of the nerve elements and the reactive changes in the neuroglia. In addition to the changes affecting the cord there often occurs involvement of the medulla, pons, crura, cerebellum, and deep central ganglia. The changes occurring here are directly related to the extension of the meningeal process along the blood-vessels into the brain substance. The changes are best marked where there are the most vessels. In the hemispheres themselves slight infiltrations are sometimes found extending in from the vessels of the fissure of Sylvius and those at the base of the brain. Whatever may be the nature of the virus, the histologic process is one which is apparently directly related to the blood-vessels and is of the nature of an exudative inflammation. As a result of the changes in the vessels there must be considerable interference with the integrity of the parts to which they are distributed. The changes in the nerve elements are thus secondary to the vascular alterations. The localization of the process in the central gray substance of the cord is explainable from the circumstance that its blood supply comes from. branches of the anterior central artery which is especially involved in the pathologic process. 1014 Cornwell Place. the role OF THE STATE IN THE prevention of ANTERIOR POLIOMYELITIS. GUY L. KIEFER, M. D. IN the February number of the Monthly Bulletin of the Ohio State Board of Health is a paper on the "Prevention of Infantile Paralysis" by Doctor M. Millikin, Health Officer of Hamilton, Ohio. The author says: "I'll tell you a story about anterior poliomyelitis, and now my story's begun I'll tell you another about its prevention, and now my story is done. After thus paraphrasing Mother Goose, I could, if I stuck strictly to the text assigned me, sit down. However, our secretary evidently expects me to preach all around the text, and, assuming that that is what is really desired, it will be in order to give some résumé of what we have recently learned of this disease." All of the above is a quotation from Doctor Millikin but I cannot even assume that your president wanted me to talk "all around the text," as he has chosen other and more able men to talk on various phases of this subject and it is up to me to say what may occur to me as rational on the subject as indicated. In our present knowledge of infantile paralysis, one fact has been established beyond any possible doubt, namely, that the disease is infectious, or certainly in some manner transmissible. This being the case it is the very first duty of the state to add anterior poliomyelitis to the list of diseases which are reportable to the department of public health. In many states, and I believe also in Michigan, the State Boards of Health have taken this step. The fact that a disease is added to the notifiable list does not, however, always bring about the desired result. It was many years after tuberculosis had been declared reportable, that it began to be reported and, even now, it is not universally done. To bring about the desired. result, that is, the reporting of cases of infantile paralysis, a campaign of education is required and, indeed, among the medical profession. The rank and file of the profession must be informed as to the prevalence of this disease and as to its communicability and they must be taught something of how an early diagnosis can be made. After the profession has been sufficiently awakened on the subject, we are ready to apply to this disease one or more of the methods in vogue for the restriction of communicable diseases, immunization, isolation, and disinfection. Unfortunately we have as yet no serum with which we can certainly render immunity but there seems to be a drug available by which we can secure at least partial immunity. It has been shown that hexamethylenetetramin (urotropin) will prevent the paralysis in many cases, and whenever the records show an outbreak in any community, it seems to me this remedy should be administered as a prophylactic measure as well as a curative one. The report As to isolation much has to be taken into consideration. ing of all, or nearly all cases would give us a more or less accurate idea of the size and severity of the outbreak. In Detroit, up to the present time, we have been unable to form any idea of the prevalence of this dis ease as our only reports consist of fatal cases and if we accept even our death records as reliable, we must conclude that there have been but few cases of the disease in our city. During the past ten years, to January 1, 1911, there have been but two deaths reported and, accepting the mortality rate as much lower than it is usually reported, we must have had a comparatively small number of cases in all of that time. During this year, however, there have been three deaths reported to date. One during January and two during February. This is due to the fact that there has been some discussion of the subject recently in our local medical society. Assuming now that a better knowledge of the subject on the part of the profession will reveal more cases in our midst, what shall we do as regards isolation of the reported cases? It has always been a fact well known to health officers, that the longer the duration of the infectivity of a given disease, the more difficult is satisfactory isolation. In other words, the people and their physicians, as a rule, will cooperate with us and aid this preventive measure if the imprisonment, as they consider it, is to be of short duration; but the longer that period the more unruly do they become. In Idaho a three weeks' quarantine has been established. Is that of any avail? It has been definitely proven that apparent recoveries from this disease and mild cases may carry the virus for weeks and probably months. It would seem, then, as though a quarantine, or certainly an isolation of the patient, should be continued for a much longer period than three weeks. In the City of New York, the Board of Health has issued a bulletin concerning infantile paralysis. This bulletin describes the symptoms of the disease and gives a variety of information on the subject. Among other things it says: "The duration of the period of infectivity is unknown, which leaves the question of isolation and quarantine unsettled." Now as to disinfection. It would hardly seem that a general room disinfection after this disease is indicated. We know that the virus is filterable and that it is undoubtedly ultramicroscopic. We know further that the nasopharynx is at least one portal of entry for this virus and that it is also eliminated through the nasopharynx. It would seem, then, as though our disinfection should be, to a great extent, local. Any materials that may have come into contact with the mouth or nose of a patient or of a carrier, if known, should be promptly burned. Especial attention. should be paid to the cleansing of the nasopharynx of persons affected with this disease or suspected of being thus affected. I have read somewhere that Wickman does not recommend the cleansing and care of the nasopharynx as a prophylactic measure. To me it seems rational, nevertheless. It would seem, then, that the duty of the State in the prevention of this disease, would be: (1) The dissemination of knowledge of the subject, as to diagnosis, prevalence, prognosis, and prophylaxis. Such knowledge to be disseminated, first among the medical profession, and then among the people at large. (2) The requiring of the reporting of all cases, this to be accomplished by the enactment of a special law, if necessary. |