there are those cases I speak of, namely, cases of chronic metritis, where we have a large, hard, indurated uterus, where the simple removal of the involved tubes does not bring about rellef. I am opposed to the removal of the ovaries in toto practically in all cases. There are some cases, of course, which demand it, but where we can save a piece of an ovary, we should do so.

As to the after sexual power of the woman, I believe that largely depends upon the conserving or preserving of those normal nerve roots that the woman naturally possesses. The one thing I insist upon is that where we remove the uterus, the whole endometrium should be taken away. Many of our failures, we will find, are due to incomplete surgical procedures. We know that many women after vaginal hysterectomy seem to get along better than after supravaginal hysterectomy. I believe the reason for that in many of these cases lies in the complete removal. The operator has gotten rid of the uterus. Where the uterus is half removed, it is not a hysterectomy, and it leaves the woman to suffer, her suffering being greater than what it was originally.

The cases Dr. Geiger spoke of that do not get well may be those of supravaginal section where the uterus has not been removed in toto.

Lastly. I hope the gentlemen do not understand me as having advocated the removal of every inflamed uterus; but it is that particular class of cases where an incomplete operation is worse than useless that I have referred tʊ, and in which a complete operation brings about permanent relief, and puts the woman upon her feet again in normal health, whereas otherwise she would not have been normal, and where there was no possibility of further child-bearing.

RACHITIS.

A. E. King, M. D., Blockton, Iowa.

ACHITIS is one of the most common diseases of childhood, occurring in fully one-half of all children, hence the importance of an early diagnosis and believe we often overlook it until great damage has resulted that is incurabie and that could have been entirely prevented had we but been more careful in our examination-as the deformity is not rickets any more than wrecks fron cyclones are cyclones. It is often called the English disease because more common there-and more common bacause more poor people with poor hygienic surroundings, poor food, poor blood, poorly nourished and poor elimination.

In the pathology we find interrupted nutrition both in and outside of the child and as in the sapling the malassimilation produces permanent alterations. Rachitis is entirely preventable and should not be associated with mollitis osseum, as the processes are entirely different, one being the destruction of bone, the other malformation of bone. We find the joints large and nodular and find on sawing through the shaft of the bone beneath the periosteum it looks like raspberry jam, and it fills the interspaces of the Haversian canal and when the change does begin it goes on very rapidly-in fact so fast that it cannot be properly deposited and so we find it in the form of ivory bone and find several teeth out closely together. At this time are formed the rachitic rosary or little nodules at the costo chondral articulations being due to an altered and deranged nutrition of the osteoplastic tissues and they are symptomatic, and if we have simply bronchitis they are likely to die because the thorax will get smaller and smaller by collapse of the lung tissue and the heart is being impinged on by the ribs and from the point of attrition. The joints first

to suffer are the knee, the radio-ulner, the ankle and then any of them it being the epiphyseal cartilages and as the proper substance for the formation of bone is not thrown out it is not assimilated but dumped as it were at the end and as the bone is lenghtened by this process we have no development and just as the animal limb is beginning to bend and as the deposit of bone is taking place almost all fractures are of the green stick variety.

In curved tibia constituting bow-legs, think is not caused so much by standing on them too soon but by allowing the child to play with the feet when young by putting them together. The square head is caused by the corners being thicker than the sides from the cranio tobes and when the child is lying on the head it is moulded in this shape and the top settles and also excites absorption by pressure.

The breast is pigeon shaped as it is contracted above and pressed out below by the liver and spleen. The child is listless, does not want to be jostled or played with, being quite the reverse of a syphilitic child. The rachitic child is a spasmodic child just as all children in proportion to improper nutrition and improper development of any or all organs but there is one kind of spasm peculiar to the child with rickets; it is known as laryngismus stridulous or the crowing disease as an immature. rooster. It being the opposite of croup and due to a relaxed condition and want of osseous development in the cartilages. It is pathog nomic and dangerous but may be cured by constitutional treatment, thereby removing the cause. We are quite likely to find it in a child. at the breast and among the first symptoms we notice the excretions from the bowels. We find them distinctly acid when they should be alkaline or neutral. Bad odor and also eructation of a bad odor. Pot belly is also an early symptom, there being distention all over the abdomen with tympany being due to a loss of tone in the abdominal muscles. We find the urine loaded with the phosphates; find them sweating about the head especially about the forehead, which is a mark of debility as night sweats in phthisis is a mark of weakness. If they do not cut teeth by the ninth month suspicion it-if not by the end of the year, be positive of it. Acid stools, head sweating and restlessness with dealyed teething are, when present, almost certainly pathognomic. Sodium chloride is required by the bones and the child takes it from the mother and by sapping her it may and does reduce her sufficiently to produce caries of the teeth. All malassimilations should be treated by better food, better blood, better surroundings, improved absorption, assimilation and elimination.

If green acid stools and sour breath, lime water and sodium phosphates sprinkled in the food. Sodium bicarbonate will correct for a time only, while sodium phosphate is permanent, but if you have regular organized rickets, use constitutional treatment, fresh air, good food, sunlight, salt baths, iron, codliver oil continually and judiciously employed. I am in the habit of administering lime water, barley water and milk, equal parts, properly seasoned with sodium chloride which seem an important factor. The treatment should be an attempt to remove the cause and the result will depend on how near this may be accomplished. Remembering the active conditions exist from the ninth to the fifteenth month and after this time the patient suffers more from the effects of the disease than from the disease itself, as most of the injury has been accomplished.

The diet should be as free from the carbohydrates as possible and consist mostly of nitrogenous food as fat, eggs, milk, cream, red meat and fresh fruit and we should not forget codliver oil either as a food or medicine. Phosphorus is highly praised by Kanowetz and the different preparations of lime by many. Iron and arsenic for anemia and atropine for

excessive perspiration.

DISCUSSION.

DR. C. A. GOOD, of St Joseph, Mo.-The subject of rickets is a pretty wel worn one, and while probably most of us are removing tubes and uteri, we will occasionally have a case of rickets to treat. Therefore, I may be excused for discussing this subject briefly.

I would hardly agree with the doctor's description of the early symptoms. The symptoms he described are the well-marked and advanced symptoms of rickets. The pot belly is rather a late symptom. Excessive malnutrition is a rather late symptom, as is also the shape of the head. I would lay particular stress on restlessness of the child at night. As to the child that is sensitive to touch, this applies more particularly to a scorbutic child. But the child who is restless at night, who rolls and tumbles, is a poor sleeper, but not particularly weak. If this is associated with profuse perspiration of the head, one should examine very closely for this condition. I have seen very little rickets, or at least, advanced more than the stage of perhaps malnutrition, if we may so call it, since I left the larger cities I do not believe we have as much in a city of this size (St. Joseph). If we have, I have not

seen it

Dr. King mentions the presence of rickets in nursing children. So far as my observation goes, I have never seen it in a nursing child except an Italian child, and a negro child. It seems that in the Southern people, who are exposed to our temperate climate, who live indoors, with poor hygiene, we occasionally have rickets in a nursing child, but it is rather an uncommon affection even in the larger cities, and I believe those who have seen many of these cases will all agree with me that they are almost always in children of the southern races.

After all, the etiology of this condition is the more important. It is not always poor food. It is very frequently due to unhygienic surroundings, and correcting the poor food and not correcting the unhygienic surroundings will not give us results. Probably the floating hospitals are doing as much for this class of unfortunates as medicines and change of diet. Anyone who has spent a few days on a floating hospital will be amazed to see how these little ones will pick up. They do not need particularly any medicines, but good food and fresh air; usually things they cannot get at home. The treatment, therefore, that is of most importance is in the way of prophylaxis.

In the early diagnosis of this condition we occasionally see it sporadically, particularly if children have been fed on proprietary foods and their homes are unhygienic. But if we wait for more than the rosary; if we wait for the craniotabes; if we wait for laryngismus stridulus, etc., they may be considered late rather than early symptoms, and I believe by a little scrutiny and by investigation of the ribs, which are, as a matter of fact, among the first bones (the wrists and ribs) to show the changes, we can make a diagnosis long before we have the advanced condition, and I believe we should.

DR. LOUIS J. DANDURANT, of St. Joseph, Mo.-This is a subject of very great interest to me, because I believe one of the most interesting cases that ever came under my observation was one of rickets.

I was called a few years ago to see a child that had been treated for quite a while by several different physicians for worms. It had taken the entire list of worm remedies on account of the symptoms which it presented. The last rescrt, which. I presumed when first told about the case, might be necessary, and would help the child, I found had been carried out, namely, the child had been circumcised.

I agree with Dr. Good as to the early symptoms of rickets, such as nervousness at night, and from a slight nervousness and restlessness up to spasms or convulsions, which we find in these children. When I saw the case, it was having a number of spasms every twenty-four hours. They told me it had suffered as

many as eighteen spasms in twenty-four hours. These spasms always began with a laryngo-spasm which we so frequently find in these cases. After a little observation and an examination of the child, I concluded the basis of the trouble was rickets. I treated it along these lines, and the improvement that child showed within a few weeks was surprising. The child at the time was twenty months of age; it had not a tooth in its head; the sutures were still wide open, and the bones were soft. After a short period of this treatment, the child showed marked signs of improvement and in less than three weeks' time the spasms had disappeared entirely, and the child from that time to this day has not had another spasm. The teeth began to grow, and appeared rapidly after they once started. The other symptoms were all alleviated, and rapid recovery was made.

I recall another case which came a little closer home. This child was put on artificial food; it was about five or six weeks of age. It seemed to be going downhill daily Everybody who saw the child said it was only a matter of a short time when it would die. When I first saw it, I thought that these predictions would prove to be true. I soon concluded that this child was not getting sufficient of the earthly salts from the artificial food they were feeding it, namely, condensed milk. I put it on the earthly salts, and I want to say, in this case I used a tablet of the earthly salts, which was placed in the milk at every nursing, and inside of one month's time it was a different child, and would not have been recognized by those who had seen it six weeks before.

DR. JOHN P. LORD, of Omaha, Nebraska.-At this late hour I will not attempt to detain the society very long: but, in my judgment, it is the duty of every physician who has under observation artificially fed children to be on the lookout for the diseases of nutrition, conspicuous among which is rickets. The fact that children who are deprived of mother's milk and are said to thrive sometimes on artificial foods that are advertised, are not necessarily children who are well nourished. The waxy appearance of the ear which will be displayed when they are between you and the light indicates they are anemic, and any anemic child should have the condition corrected lest severe nutritional changes take place.

I wish to call attention to one condition which has not been mentioned; it may be helpful to some young practitioners. I have had quite a number of children brought to me from time to time because they had spinal curvature, and it was found that they were suffering from rickets; that they had long curvature of the spine, incident to weakness. A child who has rickets develops long curvature of the spine, and is unable to sit up. A characteristic of rickets is a long curvature of the spine. Children have been brought to me after a year of age who were unable to sit up; the head would fall upon the chest, and double up like that of an infant a few weeks or a few months of age. This is very characteristic of rickets. I do not refer to the cases of born imbeciles or idiots, but I mean a weakness or dropping of the head from rickets.

DR. KING (closing the discussion).—I wish to thank the gentlemen for the kind and liberal way in which they have discussed my paper.

In regard to the first symptoms, they certainly misunderstood what I said. My paper stated that the first symptoms were noticed in the discharges in the bowels, the eructation of gases, bad odor, showing at first disturbance in the intestinal tract. Afterwards, the cranio tabes, the rachitic rosary, and pot belly were referred to. The reason we do not see more of these cases is because we are not careful enough in examining them. We are not able to recognize them on the street. We should be able to do so. I have seen plenty of them here in St. Joseph. It is the after-effects we notice instead of the primary effects or earlier symptoms. Those are the ones we should recognize early. The condition of the bowels, the brow sweating, the restlessness at night, eructation of gases, sour discharges from the bowel, and bad odor, are among the first symptoms. I thank you.

My desire and aim have been to utter nothing but the truth. I have no love for error in any form or in any field of knowledge.-Hiram Christopher

The Medical Herald.

Discussion of Current Topics invited in this department. The Editors assume no responsibility for the views expressed by correspondents.]

OPENING OF THE ENSWORTH-CENTRAL MEDICAL COLLEGE, SEPTEMBER 15, 1906.

At this time of the year the medical student looks about for a medical college either as a beginner of the study of medicine or as one who wishes to make a change. Medical science is taught in two main directions. First with a view to the complete scientific, laboratory and clinical training of the student, while secondly, the training of the student to become a practicing physician and only such scientific and laboratory training as is sufficient to give him an acquaintance with their practical aspects. In the larger cities surgeons do not make chemical or bacteriological investi gations to make a diagnosis or give a prognosis, they simply refer these examinations to the chemist or bacteriologist. The same holds good for the pathological histologist. In this laboratory work very few succeed even after a proper degree of sufficiency on leaving the college, an infinitely small number can make any of these examinations satisfactorily, five years after graduation. When the physician's practice increases the time element alone speaks against it. Therefore, he who simply wishes to become a practitioner of medicine, should devote his time to the more practical and clinical side and he need not put in so many years in the theoretical relations of laboratory study. Bacteriology occupies a great deal of the student's curriculum, yet its practical importance is limited. Of what use is a knowledge of the natural history of bacteria to the ordinary practitioner? To one who pursues studies along these lines and makes it a specialty this knowledge so acquired is essential. Let the prospective student cast about him and understand that which he undertakes. He must try and find a school which helps him in the study of the solution. of the many problems found in connection with patients. He must study