are all reversed. The conjunctivitis caused by the staphylococcus and streptococcus is almost always marked by severe symptoms, among them the formation of a pseudomembrane, which is often with difficulty to be distinguished from a diphtheritic membrane, in spite of microscopical examination.

A brief study of a few of the more common forms of infection of the conjunctiva may help us to a conclusion as to when to operate, if at all, in the presence of infection.

There are several forms of conjunctivitis due to the streptococcic infection. The most common form is distinguished by marked engorgment of the conjunctival and subconjunctival vessels, slight secretion and slight swelling of the lids. Another form, due to the same microbic infection, shows a thin membrane or pellicle, and is called pseudomembranous. The common name of streptococcic conjunctivitis depends upon the abundant presence of the streptococcus in the secretion, and the impossibility of explaining the clinical symptoms without its intervention, though there may be other microbes associated with it, which do not explain the gravity of the inflammation. The false membrane is not always present, and is generally of extreme tenuity. There is always some swelling of the lids, and almost always a pre-auricular adenitis. The presence in the secretion of cocci disposed in chains does not prove it to be the streptococcus, for the pneumococcus does the same thing. The bacilli occur more frequently as disseminated diplococci, not to be distinguished from the staphylococcus and pneumococcus. There is no one pathognomonic symptom, but the general complex of symptoms will aid in the diagnosis, while a full demonstration is only furnished by cultivation and inoculation, and the bacilli should be numerous in the secretion and cultures. It should not be forgotten that the streptococcus, the staphylococcus, and the diphtheria bacillus may exist in the conjunctival sac without exciting any reaction, and infection can only occur in the presence of traumatism.

In operative cases the streptococcic infection is very grave, and generally leads to rapid perforation of the cornea and general suppuration of the eyeball. It is always difficult to trace the way in which this infection has occurred, or to determine the conditions which have facilitated its development. It is certain that in many cases the infection is developed in preexisting forms of conjunctivitis, and it is probable that it would not have occurred without a preceding loss of epithelium. It is very doubtful if a streptococcic infection could be developed in a healthy conjunctiva, and we must regard it as a secondary inflammatory process.

Most of these cases doubtless come from the lacrymal sac, for there is usually slight redness and swelling over the sac and tenderness on pressure, and more or less swelling of the pre-auricular gland, and more rarely of the parotid and submaxillary glands. The conjunctivitis due to pneumococcus infection is much rarer than that due to infection by the streptococcus or staphylococcus. It occurs mainly in young persons, and seems to be most prevalent in spring or autumn. Its appearance may be either sporadic or epidemic. It is sometimes met with in children with measles and bronchopneumonia, and here the symptoms are very severe, especially on the side of the cornea, which rapidly ulcerates, becomes deeply infiltrated, perforates, and ends in panophthalmitis and sometimes in the death of the patient. The pneumococcus seems to occur more frequently in certain localities. For instance, Rymowicz reports that in Kasan the pneumococcus conjunctivitis ranged from 18 per cent. to 36 per cent. of the cases, and was often accompanied by iritis

and cyclitis, probably from development of toxins. In all the cases reported the pneumococcus has bet. found in great abundance in the secretion. At other times the symptoms are slight, the cornea is not involved, or if so, only superficially, and the pneumococci are few in number.

In the case of an infected lacrymal sac, the cond tion is somewhat more grave. The contents of a suppurating tear-sac are extremely infectious. It needs but a small wound in the cornea, the slightest injury to the corneal epithelium, to set up the most destructive process, ulcus serpens. Yet it well-known fact that many patients have suffe for years from suppuration of the lacrymal sac with out any infection of the conjunctiva or come Some two years ago, Stock (Klinische Monattsbläte für Augenheilkunde, 1902, p. 116) instituted some experiments on rabbits. The lacrymal sac was a fected by the Bacillus pyogenus, Bacillus prodips sus, and the Staphylococcus aureus, and he wattal the animals for a varying length of time without sult. He satisfied himself that the normal uninj conjunctival sac of the rabbit could not be infecte and that if the lacrymal sac were extirpated or t lacrymal puncta cauterized by the galvano-cautar no germs could enter the conjunctival sac from:

nose.

Hirota (Zentralblatt für Bakteriologie, 31. He carried out similar experiments about the s time. He found that the bacilli of septice and of hen cholera, and the pneumococcus, duced into the conjunctival sac of the nt. only succeeded in infecting it when traumati was present. He also incidentally demonta the influence of the lid action upon the gem tents of the conjunctival sac, by finding that b teria introduced into the sac all disappeared *** ten minutes after the use of irrigating fluids.

In the light of our past experience and ri knowledge gained from the numerous experime instituted and carried out on animals, it bec absolutely important that all diseases of the lids, edges of the lids, conjunctiva and lac passages, whether suppurative or not, shon treated and cured before undertaking any tion on the eyeball or conjunctiva. C dacryocystitis is the most dangerous sour infection, and if a persistent inflammation a lacrymal sac resists treatment, the puncta mui obliterated by the actual cautery, or the art sac must be excised. We have learned by ments that the bactericidal properties f attributed to the natural lacrymal secretion tears, do not exist. It is true that s operations on the eyeball have been performa the presence of chronic dacryocystitis, but risk is too great to countenance such unwise an and the same may be said of operations eyeball in the presence of trachoma with pu discharge. It is by no means safe or wis guided in our decision as to operating, appearance and secretion of the conjunctiva : when the mucous membrane is smooth and r red and swollen, for an inflamed conjunctiva. is never to be trusted. Even after a caref teriological examination has been made with a tive results, all the steps of an operation be carried out with the least bruising and vi in order to avoid preparing a soil in which tend to multiply; and we should not where avoidable in cases in which und constitutional conditions exist, as these directly be provocative of pathogen growth.

All this brings us round again to the everg

question: how can the danger of infection be best avoided? From the bacteriological standpoint it would seem that the most favorable results are to be gained by mechanical cleansing of the eyelids and lid-margins and simultaneous irrigation. I do not believe that anything is to be gained by using concentrated antiseptic solutions over indifferent fluids like normal salt or boric acid solutions for purposes of irrigation. Repeated mechanical cleansing with warm water and soap may do for the region surrounding the eyes, the forehead. eyebrows, temple, and cheek, and the external surface and edges of the lids, but the delicate conjunctiva will not bear such rough handling, and is positively injured by the loss of its epithelium, thus leaving openings for the free entrance of germs.

After the forehead, temple, cheek, external lid surfaces, and edges of the lids have been mechanically cleansed in the way mentioned, the conjunctival sac should be repeatedly irrigated with some indifferent sterilized irrigating fluid, and then the fluid collected in the conjunctival sac should be mopped up with sterilized moist cotton pads, before beginning the operation. Operating in this 30-called dry manner prevents the entrance of this luid into the wound, and thus the danger of actully pressing any possibly existing germs into the ips of the wound is avoided.

If care has been taken to avoid operating in the resence of a positively infected conjunctival sac, nd if no infection has been introduced during the peration, we may almost with certainty expect a apid and favorable healing of the wound. The pare occurrence of infection after operation may, erhaps, be explained by the fact that toxic bacria are not always present, and that when present, ey are not met with in great numbers, and conquently their virulence is slight, for the danger infection increases with the number of bacteria esent in the sac, and in contact with the wound. has been thought by some skilled operators that have another means at our command for prenting infection after an operation, by doing ay with the ordinary protective bandage, and otecting the eye merely by the mask, on the nciple that the natural motion of the lids is a lued factor in the normal cleansing of the connctival sac. From a bacteriological standpoint is is theoretically correct. But the nature and iperament of the patient must always be conered. In a patient of quiet, equable temperant, it might be entirely safe to close the lids. a strip of adhesive plaster, and protect the eye n external injury by a mask, but in the maty of cases the writer is convinced that the : of such a procedure would be too great, ng to the restlessness and irresponsibility of the

ent.

ummary.-I. A careful microscopical and bacological examination should be made of the tents of the conjunctival sac in every suspected , carrying the examination as far as the cultion of the bacteria in a proper medium, and the equent inoculation of the germs.

. If toxic germs are found in great numbers, matter what their varieties, no operation on eyeball should be undertaken until the germs › disappeared, and the conjunctival sac has rendered as sterile as we can hope to make it. I. If there be suppurative disease of the lacrypassages, whether of canaliculi, sac, or nasal

all operations upon the eyeball are posiy contraindicated. The lacrymal sac must xcised, and the lacrymal puncta must be ob

literated by the galvano-cautery, before any operation on the eyeball is undertaken. In the case of a catarrhal dacryocystitis, or of mucocele of the sac, both canaliculi should be incised, and the sac injected daily with an antiseptic astringent solution, and free irrigation through the nasal duct carried out until all secretion has ceased. Even in cases of great urgency, as, for example, acute inflammatory glaucoma, the writer would not feel himself justified in modifying the above statement.

IV. If the secretion of the conjunctival sac on examination is found to be infected, but the bacteria are few in number and of slight toxic variety, operations may be done on the eyeball when necessary, but these eyes should be opened and examined twice in the twenty-four hours, and the conjunctival sac gently irrigated with warm normal salt solution, or warm sterilized boracic acid solution, and then the eye should be immediately rebandaged. V. In operating upon the eyeball in the presence of an apparently normal, sterile conjunctival sac, the following steps should be taken:

Ist. The forehead, eyebrows, temple, cheek, bridge of the nose, and external surface of the lid should be carefully cleansed with hot water and soap, and dried with aseptic cotton pads.

cotton

2d. The margins of the lids should be carefully but gently rubbed with sterilized moist pads, and simultaneously irrigated with a warm sterilized physiological salt solution.

3d. Careful irrigation of the conjunctival sac with the same sterilized normal salt solution, and then closing the lids with a moist sterilized cotton pad. The lids should remain closed in this way until the speculum is introduced.

VI. In all cases the bandage should be removed and the eye examined under the strictest aseptic precautions, as strict as those employed at the time of operation.

VII. On the first sign of infection of the wound, the edges of the lids are to be thoroughly cleansed in the same manner as at the time of operation; the conjunctival sac is to be thoroughly irrigated with the sterilized normal salt solution; the wound is to be reopened and cauterized through its entire length with the galvano-cautery; and the anterior chamber is to be gently but carefully irrigated with a sublimate solution (1-5000); and then the conjunctival sac must be again irrigated, and the lids must be closed simply under a moist sterilized pad.

47 WEST THIRTY-SIXTH STREET

The Causes of Gout.-Falkenstein has claimed that gout is due to a disease of those glands in the fundus of the stomach which are concerned with the excretion of hydrochloric acid, and in consequence of this, exhibit a diminished power. The absence of one of the main factors in digestion causes an insufficient solution of the fibrin in the food and the peptogenic action is inhibited. This leads to the development of foul gases and organic acids. The various urates are not sufficiently broken up, but are absorbed by the blood and deposited in the tissues. Here they remain until solution results as the cause of some other intermediate factor and the irritation produced by their presence in the tissues leads to the inflammatory disturbances recognized as the gouty attacks. As the result of extended experience, Falkenstein has found that gouty individuals can take considerable amounts of hydrochloric acid for prolonged periods with good results as regards the general health and the disappearance of localized deposits. This treatment may be associated with a generous mixed diet, moderate in amount. The only substances contraindicated are sugar, foods rich in nuclein (such as the internal organs of animals), fats, smoked meats, cheese, and eggs.-Wiener klinische Rundschau.

THE history of athletics has blended intimately with medicine, and feats of agility and endurance have at all times excited the interest and investigation of capable and reputable physicians, for they are in every sense of the word examples of physiological and functional anomalies. The word athletics was derived from the Greek athlete which was the designation of persons among the Greeks and Romans who contended for prizes in public games. This was prior to 400 B. C. The system was purely Greek, as were the athletes, although the Romans admired physical skill and strength. No institution exercised a greater influence on molding the national character, and producing that unique type of physical and intellectual beauty which we see reflected in Greek art and literature than the public contests of Greece.

The earliest games of which we have any record are those at the funeral of Patuclus. The belief that the dead would be gratified by the same exhibitions which pleased them in life was a common heritage of the Greeks and Romans from their Aryan progenitors. The competitions were chariot racing, archery, boxing, wrestling, and putting the weight.

In 776 B. C. the Elerians engraved the name of Coræbus as victor in a foot race. This is the earliest record of any contest. Ten months was what all the athletes swore to having taken in preparation for the games at Olympia. Herodicies, who lived 500 B. C., was the founder of medical gymnastics.

The different phases of athletics might be designated as follows:1 (1) Games and sports that depend wholly or partly on feats of physical strength, such as baseball, cricket, rowing, and swimming. (2) In a restricted sense, feats of strength performed for their own sake, and not as an incident of any game, as throwing the hammer, running, leaping, tumbling, etc., especially outdoor feats in which the maintenance of health is not the prime object. (3) Any system of physical training by gymnastic exercises and outdoor sports.

The physiology of exercise may be epitomized as follows: It increases the action of the heart, causing the blood to flow more freely through the circulation; it increases the rapidity of respiration; dilates the capillaries; increases the activity of the glandular secretions; causes diaphoresis, and incites all the internal organs to act more energetically. It is well to note that exercise calls into play the involuntary as well as the voluntary muscles and that chemical changes are going on in consequence.

Jäger' says that gymnastic exercise is most important for the proper development of the muscles and motor power, and ought to be commenced in both sexes at an early age. Systematic muscular activity increases the volume of the muscles and enables them to do more work. The amount of blood is increased with increase in muscular development, while at the same time the bones and ligaments become more resistant. As the circulation is more active in an active muscle, gymnastics favors the circulation. An active muscle also uses more oxygen and produces more carbonic oxide, so that respiration is also excited. The total increase of the metabolism gives rise to the feeling of well-being and vigor, diminishes abnormal irritability, and dispels the tendency to fatigue. The whole body becomes firmer and specifically heavier.

All exercises used in medicine are based on Ling's or the Swedish system, which consists of systematic attempts made to strengthen certain weak muscles, or groups of muscles, whose weakness might lead to

the production of deformities. These muscles are exercised systematically by opposing to them resis tances, which either must be overcome, or against which the patient must strive by muscular action.

Holmes presents the following as a summary of his paper entitled "The Capacity of Human Musce for Work": (1) A muscle working under normal physiological conditions is neither "loaded" nor "after-loaded." (2) A muscle will not contract isotonically nor isometrically under normal physiologi cal conditions. (3) When an ergograph is used, a large part of the energy expended by the muscle during a period of work is lost; this loss occurs in easing back the weight or the spring to its position of rest or to the zero point. (4) A recognition of the conditions under which a muscle works and of the end to be attained is necessary when an interpretation of ergographic results is to be made. (5) A normal mustlar contraction consists in contraction, relaxation without load, rest. (6) A muscle can work or periods of long duration without fatigue when the conditions are favorable. (7) These experiments confirm the conclusion stated by Maggiora that ther is a definite weight with which one can perform the greatest possible work. (8) The physiological lim of a muscle for continuous work is modified by the rate, load, and interval or by rest and work

Physical Overexertion and Its Effects on HealthJohn Knott emphasizes the fact that exercise order to do good, must be indulged in with mod tion. In analyzing the effects of exercise he s that in an active muscle nutritive changes take p far more rapidly and on a larger scale than in a rest ing one. The waste products are carried off in lart quantities and new materials are absorbed w greater rapidity. Again, muscle forms so lary proportion of the mass of the body that it is k as the great furnace of the animal economy, ab four-fifths of the total heat of the system being >> volved within it. It is most important to main. a healthy functional activity of the muscular syst With the increase of the muscular action the an of waste products is also increased. Up to a certa point the system is able to eliminate this waste in overexertion a point is reached beyond which effete products begin to accumulate in the circular and in the tissues. Fatigue then becomes manif

When the muscular fatigue is carried to ext the healthy nutrition of the other organs and tist can no longer be maintained. This con lition be special effect on the nerve centers. When the tion of the latter becomes deranged, the nutr changes and functional capacities of the whole sys are disturbed. In the excessive muscular exer which takes place in running the "brain is overs by a kind of drunkenness." He believes that fever of overexertion is due to the poisoning nerve centers by the muscular waste products. heat regulating centers lose their governing po and the body wastes with slow fever. The? various local affections which are likely to be duced by excessive exercise, such as hyper and dilatation of the heart, aneurysm, and van veins. It is necessary for even those who have blessed with an unusual physique to remember the overuse of the body may lead to a sudde permanent breakdown of health.

Violent or prolonged exertion often indus porary albuminuria. Casts' have been found in urine after a boxing bout when examination other times showed nothing abnormal.

as

Overexertion produces mental fatigue, athletes will acknowledge. One instance SA cited in which an individual after a long hi could not remember his companion's name

he knew him intimately. This condition is probably the result of an interference in the blood pressure. Recently there appeared in the obituary column of one of our medical journals the death notices of two physicians who had in their college days excelled in athletics, one at football playing and the other at rowing. The former died of appendicitis and the latter, as the notice read, "of an attack of pneumonia which his weak heart was unable to withstand owing to former hard athletic work in college." Within the past few months the deaths of several noted athletes have been recorded, all occasioned by renal and cardiac disease. One of these was a young woman of twenty-three, who excelled as a swimmer.

A recent writer of an article on "Neurasthenia,' in speaking of the etiology of this condition, says: "To the mental training there has also to be added the schoolmaster's craze for athletic development, often carried far beyond the physical strength of the growing boy or girl, and again leading to a depletion. of the reserves of energy, which bodes ill for the future capital account of those who, in youth, are compelled to give such hostages to the fortune of their vitality."

In the year 1903 there were thirty-five deaths from ootball, 500 severe injuries, and sixteen cases of pinal injuries followed by paralysis. Of the 343 ractures, most of them were of the bones of the leg nd forearm, ninety-one of the clavicle, nineteen of he femur, and four of the skull. In commenting on hese fatalities and injuries, the Journal of the Ameran Medical Association' says: "The vital question does the gain in college pride and college spirit Ifficiently outweigh this list of human wreckage?" r. Lawrence Johnson has said that a young man in well-contested rowing race, lasting twenty-five inutes, would use up as much energy as he would tually require ordinarily in a lifetime of eighty

ars.

An experienced athlete, in a recent conversation th the writer, gave as his opinion that a man sacries a certain number of years of his life every time enters a contest of any kind. He also said that a in when "fit," as expressed by athletes, is in an normally nervous condition. In other words, he 1 never remain at ease for a minute at a time, and e the caged lion is forever on the move during his king moments. It has been noticed by observers at athletes are often sickly and particularly sustible to constipation and appendicitis. A case been related in which a strong man, although sick h phthisis pulmonalis, performed his feats of ngth up to a short time preceding his death. t has been said that the muscles of old athletes prone to degeneration unless, as is rarely the , exercise is continued. Cardiac hypertrophy is commonly found in athletes that the condition been named "athlete's heart." Like all hyper >hied muscle tissue it is susceptible to degenerain the same manner as the blacksmith's right ecords kept in gymnasiums show that when a cle has been hypertrophied by exercise in a short od of time, and the exercise has then been disinued, the measurement very soon drops back he original figure. The writer has tried this riment in two cases with the same result. The nges that go on in the muscle of the pregnant us and the tendency of the same toward degenon when the vital powers of the individual begin -ane are an instance of the great susceptibility pertrophied muscle to degenerate. alvular murmurs are frequently found in athletes there can be no doubt that the preceding hyperThe ny was an etiological factor in these cases.

writer has in mind at the present time a case in line with the foregoing in which a boy of twelve developed a well-marked murmur after a few weeks' overexertion in riding the wheel.

It is a disputed question whether athletics can cause renal disease. The presence of albumin and casts in the urine upon exertion or overexertion would lead one to believe that renal disease might be the ultimate result, inasmuch as nearly all authorities agree that albuminuria is never physiological. One case occurred in the experience of the writer in which persistent albuminuria was present in a young man of marked athletic tendencies who later developed pulmonary tuberculosis which caused his death after an illness of a few months. In this particular case the family history was negative

Another case may be cited of a young man who as an amateur sprinter won contests and medals galore. It was a well-known fact that he always fainted as he broke the tape. He is now going through life with a damaged heart as a result of this severe athletic work. Sudden deaths have occurred while wheeling, dancing, wrestling, boxing, running, rowing, lifting heavy weights, and bowling. It has often been said that many athletes are sexual perverts, and investigation reveals the fact that there are good grounds for such statements. We might explain this condition by stating that severe athletic training and muscle building are at the expense of the nervous and glandular systems.

A few years ago the writer's attention was called to a professional gymnast possessing great strength who was practically impotent. It has been observed by a few that the best athletes possess poorly developed sexual organs. A supposed authority upon matters pertaining to athletics recently made the following satements: "The question of race suicide brings up another point, namely, the effect of severe athletic training upon the sexual power. Physical culture extremists preach that massive masses of muscle are an indication of 'superb manhood.' Facts fail to bear out this theory, the truth of the matter being that severe physical exertion has exactly the opposite effect. This is true, not only in the case of human beings, but also with any animal. It is a well known fact that the surest way to ruin animals for breeding purposes is to compel them to perform hard work.

We need only to look up the records of America's prominent physical culturists and professional athletes, to be convinced of the truth of the above statements. It will be found that comparatively few athletes marry. Of those that do marry, a small percentage have children. A large percentage are divorced by their wives, and it is doubtless true that not a few completely lose the instinct of the normal man."

Benefits of Athletics.-In regard to the benefit derived from athletics one has only to remember the physiology of exercise to become convinced of the fact that exercise per se may be very beneficial. The point to bear in mind is to advise the person to stop before fatigue becomes evident. We can do this readily when the athlete is interested in games for the mere exercise, but such advice cannot be offered when his aim is to excel in an athletic contest. Here is where athletics do great harm, and it would be a safe rule to advise against all forms of athletics in the nature of a contest, especially if the person be not in robust health.

Athletics may be said to be beneficial until the heart begins to be markedly hypertrophied; this is the danger signal. A person in such a condition might indulge in light forms of exercise, but should be strongly advised against entering any contest.

In