TRANSACTIONS

OF THE

C O N G R ES S

AmericanPhysicians and Surgeons

F O UR T E E N T H T R I E N N I A L S E S S I O N

HELD AT

WA H NGT D (i S O N . I , .

M a l s t and nd 19 8 y 2 , 2

PUBLISHED BY THE CONGRESS

N NNN NNNNN NNNNN Ente r e d ac c o rding to Ac t o f Co ngre ss i n th e y e ar 1 93 0

R TEI N R MD e r h n b WALTER . E . . e c r ta o f t e Co r e s s y S , , S y g

o f Copies may be had the Secretary .

T HE T UTTLE MO REHO US E TAYLOR CO MP ANY NEW HAVEN ONN , , , C . TAB LE OF C ONTENT S

Table o f Contents

Titles O f Papers to be read at Congress

Officers O f th e Cong ress

Executive Co mmittee

Committe e O f Arrang e me nts

Past Officers o f th e Cong ress

By -Laws o f the Cong ress

Minute s Of th e Fourteenth Sessiono f th e Cong re ss

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’ THE PRESIDENT S ADDRES S :— THE DECLINE OF INFECTIOUS DISEASES IN ITS RELATI ON TO O B OB M DERN MEDICINE ; Y D R. THE ALD SMITH

THE HEART 19-90

DR V 1 — 8 ECONOMIC ASPECTS OF HEART DISEASE ; by . HA EN EMERSON 9 3

HE R DR E -6 1 H . S T EA T IN INFECTION ; by . HOM R F WIFT 39

— E H EA D L . H E 62 TH EFFECT OF STRAIN ON T E H RT ; by R. PAU D W IT 75

H E DR COMMENTS ON T E TREATM NT OF HEART DISEASE ; by . B R K JAMES . HE RIC

D ISCUSSION DR . E . P . CARTER DR H . A . E . CO N DR NE . GEORGE CA Y ROBINSON DR W L . HENRY SE A L

DR . LOUIS FAUGERES BISHOP V DR. S . A . LE INE W DR . HOMER F . S IFT DR H . PAUL D . W ITE BUSINES S SES SI ON OF THE CO NGRES S

OFFICERS O F THE C ONGRES S

O F

1 92 8

P RES ID EN T . n OB . . i t . . THE ALD SMITH , M D , Pr ce on , N J

- - C P S N S e x o ffic i o . VI E RE I D E T , n n O B t . A . MCKENZIE F R ES , Mo real , Ca ada

PRESIDENT OF THE AMERICAN ORTHOPEDIC ASSOCIATION .

X O . J . CLA T N GITTINGS , Philadelphia, Pa

PRESIDENT OF THE AMERICAN PEDIATRIC SOCIETY .

OBLIN . JAMES W . J G, New York City PRESIDENT OF THE AMERICAN ASSOCIATION OF PATHOLOGISTS AND

BACTERIOLOGISTS . B WALTER E . LAM ERT, New York City . H E H H E PRESIDENT OF T E AM RICAN OP T ALMOLOGICAL SOCI TY .

MAX . u O . A . G LDSTEIN , St Lo is

PRESIDENT OF THE AMERICAN OTOLOGICAL SOCIETY .

CHARLES L . DANA , New York City .

PRESIDENT OF THE AMERI CAN NEUROLOGICAL ASSOCIATION .

BRETTA ER O U . J SEPH , New York City H PRESIDENT OF T E AMERICAN GYNECOLOGICAL SOCIETY .

ER TER u . O O . O S TT H F , Milwa kee, Wisc

PRESIDENT OF THE AMERICAN DERMATOLOGICAL ASSOCIATION . n . B t . . CHARLES S UTLER , Washing o , D C H M A PRESIDENT OF T E A ERICAN SOCIETY OF TROPIC L MEDICINE. B O . D . RYS N DELAVAN , New York City R P ESIDENT OF THE AMERICAN LARYNGOLOGICAL ASSOCIATION .

X O n EMMET RI F RD , San Fra cisco , Cal . I PRESIDENT OF THE AMER CAN SURGICAL ASSOCIATION .

O . J SEPH H PRATT , Boston , Mass . PRESIDENT OF THE AMERICAN CLIMATOLOGICAL AND CLINICAL

ASSOCIATION . OF T HE iv OFFICERS CONGRESS .

h DR . o c . . ALDRED S WARTHIN , Ann Arb r, Mi H C H PRESIDENT OF T E A SSOCIATION OF AMERI AN P YSICIANS .

B B Ne w R . D . HENRY G . UG EE , York City H R - PRESIDENT OF T E AME ICAN ASSOCIATION OF GENITO URINARY SURGEONS .

DR . St. u s . EVARTS A GRAHAM , Lo i , MO . H H U E PRESIDENT OF T E AMERICAN ASSOCIATION FOR T ORACIC S RG RY .

A E S R R. S ECRETARY . T RE U

R O . R W T D . D . . AL ER R STEINER , J HN E LANE,

St . 6 6 u . 4 Asyl m Ave , 59 Colleg e , n nn f . Hart ord, Conn . New Have , Co

E EXE CUTIV E CO MMITTE .

A ALT * 2 1 n RM 6 . n h i an DR W . S . arm . C C , ILLIAM H , St Ro a t n New Haven, Co n .

n n D R De le ate . . D . . . t L S GREENE, g , Washi g o , C n l n . A te rnat . R . B D . O e t J HN W URKE , , Washi g o , D C

Re pre s e nting th e AMERICAN OPHTHALMOLOGICAL SOCIETY .

n DR O De le ate t . . . CHARLES W . RICHARDS N , g , Washing o , D C

DR B Alt rna t . O e te . . J SEPH RYAN , , Washing on , D C Re e tin t ER L ET pr sen g he AM ICAN OTOLOGICA SOCI Y.

l n . R D ate t . D . W W e e ILLIAM A . HITE , g , Washing o , D C l DR . A rnate . . . T te J RAMSEY HUN , , New York City, N Y i h Re pre s e nt ng t e AMERICAN NEUROLOGICAL SOCIETY .

* DR . . D l t . B W O e e a e . J ESLEY VEE , g , Washington , D C DR n Alt t . . B n t O e r a e . . G R WN MILLER , , Washing o , D C

Re pre se nting th e AMERICAN GYNECOLOGICAL SOCIETY .

DR LLI R . P O TZE D l ate . e e . SIGMUND , g , New York City, N Y DR . O . Alt r t nn e na e . J HN E LANE , , New Haven, Co

Re pre se nting th e AMERICAN DERMATOLOGICAL ASSOCIATION .

DR O . . B D l at n . e e e t . J SEPH H RYAN , g , Washing o , D C DR . . B O Al nat te r e t . D RYS N DELAVAN , , New York Ci y , N . Y R e pre s e nting th e AMERICAN LARYNGOLOGICAL ASSOCIATION .

DR * . ARMALT n . C De le ate Ne w n n WILLIAM H , g , Have , Co . DR . . Al at te rn e . . JAMES F MITCHELL, , Washington , D C R e pre se nting th e AMERICAN SURGICAL ASSOCIATION . OFFICERS OF TH E CONGRESS .

O De le ate . . DR. THOMAS DARLINGT N , g , New York City, N Y

DO CHEZ Alte rnate . . DR. ALPHONSE , , New York City , N Y I Re pre s e nting th e AMERICAN CLIMATOLOGICAL AND CLIN CAL ASSOCIATION .

ATT D l at WO ODY e e e . R O . D . R LLIN T , g , Chicago, Ill

B BB Alte rnate o o . R . D . GERALD WE , , Colorado Springs , C l

Re pr e s e nting th e ASSOCIATION OF AMERICAN PHYSICIANS .

De le ate t . . DR . . FRANCI S R HAGNER , g , Washing on, D C

O Alte rnate . DR . . HUGH H Y UNG, , Baltimore , Md - R Re p re s e nting th e AMERICAN ASSOCIATION OF GENITO URINA Y SURGEONS .

De le ate . R . B D . WILLIAM S AER, g , Baltimore , Md l B A te rnate . DR . . A RUCE GILL, , Philadelphia , Pa O H Re pre s e nting th e AMERICAN RT OPEDIC ASSOCIATION .

l ate De e . DR . . . J . P C GRIFFITH , g , Philadelphia, Pa * l n . A te rnate . DR . t . SAMUEL S ADAMS , , Washi g on , D C

Re pr e se nting th e AMERICAN PEDIATRIC SOCIETY .

l DR. . De e ate . PAUL A LEWI S , g , Philadelphia, Pa

DR Alte rnate . . JAMES EWING, , New York City, N Y . Re pre se nting th e AMERICAN ASSOCIATION OF PATHOLOGISTS AND B R ACTE IOLOGISTS .

DR . l a O De e te . . . t J SEPH F SILER , g , Washing on , D C Alt at e rn e , i h Re pre s e nt ng t e AMERICAN SOCIETY OF TROPICAL MEDICINE .

DR B O . R. D l te . e e a . R ERT T MILLER , J , g , Baltimore, Md DR O . u . t . J HN L YATES , Al ernate, Milwa kee , Wisc Re r e ntin h RA p e s g t e AMERICAN ASSOCIATION FOR THO CIC SURGERY .

Deceased .

MMI T EE F A RANGEMEN CO T O R TS .

DR . O . 1 1 n 0 . W . . t . . L UIS S GREENE, 7 Rhode Island Ave , N , Washing o , D C O th R O H HA I f e AME ICAN P T LMOLOGICAL SOC ETY .

DR O . . . 1 0 1 u W. SCAR A M MC KIMMIE, 3 Massach setts Ave . , N . , Wash in n to . . O th e O g , D C f AMERICAN TOLOGICAL SOCIETY .

DR ’ . W . S . z s t . . ILLIAM A WHITE, t Eli abeth Hospi al , Washington , D C O th e f AMERICAN NEUROLOGICAL ASSOCIATION .

DR . . B O 1 W 0 W. i n G R N MILLER, 73 K Street , N . , Wash ngto , D . C . O th e E f AM RICAN GYNECOLOGICAL SOCIETY .

DR . . 1 1 2 t e . HENRY H HAZEN , 9 R S re t , Washington, D C . O th e f AMERICAN DERMATOLOGICAL ASSOCIATION . OF T HE v i OFFICERS CONGRESS .

B 0 u t . . DR O . . J SEPH H RYAN , 3 3 Stoneleigh Co rt, Washing on, D C O th e R f AME ICAN LARYNGOLOGICAL ASSOCIATION .

h . 1 1 t . W t . DR. JAMES F . MITCHELL, 344 9 Street , N , Washing on , D C . O th e f AMERICAN SURGICAL ASSOCIATION .

1 82 6 W. . O . t R O . . D . TH MAS A CLAYT R , R Street , N , Washing on, D C th e R Of AME ICAN CLIMATOLOGICAL AND CLINICAL ASSOCIATION .

2 W. DR. . . t . . WILLIAM C WHITE, 334 Nineteenth Street , N , Washing on , D C O th e H f ASSOCIATION OF AMERICAN P YSICIANS .

Th u DR. . e . . FRANCIS R HAGNER , Farrag t , Washington , D C O th e R - A f AME ICAN ASSOCIATION OF GENITO URIN RY SURGEONS .

DR . 01 W. . . AURELIUS R SHAND S , 9 Sixteenth Street, N . , Washington, D C . th R O H H O e . f AME ICAN RT OPEDIC ASSOCIATION, C AIRMAN OF COMMITTEE

DR 1 861 Minfwo o d O O O . . t J HN F TE , Place , Washing on, D C . O th e f AMERICAN PEDIATRIC SOCIETY .

DR O . u u n . t . . GE RGE R CALLENDER , Army Medical M se m , Washing o , D C h e H B Of t AMERICAN ASSOCIATION OF PAT OLOGISTS AND ACTERIOLOGISTS . n DR. . e . . EDWARD R STITT, Navy D partment, Washingto , D C th E Of e AMERICAN SOCIETY OF TROPICAL MEDICIN .

DR. 1 . W. . . t t JAMES F MITCHELL, 344 Nineteenth S reet, N , Washing on, D C . I H Of th e AMERICAN SOC ETY FOR T ORACIC SURGERY . PAST OFFI CERS OF TH E CONGRESS V i i

P RE S I D EN TS .

— D H . B . . 1 88 R. 8 JO N S ILLINGS , Washington , D C — H P . DR . I 1 . 89 S WEIR MITC ELL, hiladelphia, Pa

~ - DR . . 1 894 . ALFRED L LOOMIS , New York City

— 8 DR . H . I 97 . WILLIAM H WELC , Baltimore , Md — . B W H D . I gOO R. HENRY P O DITC , Boston, Mass — DR . . 1 903 . WILLIAM W KEEN, Philadelphia, Pa — F DR . ITz . 0 . I 9 7 REGINALD H , Boston , Mass — W . DR . . I IO . o ED ARD L TRUDEAU, Saranac Lake , N Y

— DR . 1 1 . . 9 3 WILLIAM C GORGAS , Ancon , Canal Zone — H DR . . 1 1 6 . 9 WILLIAM S T AYER, Baltimore , Md — D 1 1 R. . 9 9 SIMON FLEXNER, New York City 2 2 — DR K B I 1 . . 9 FRAN LLINGS , Chicago , Ill — 1 2 DR . 9 5 . WILLIAM J MAYO, Rochester , Minn . 1 2 8— DR H E L H n n 9 . T OBA D SMIT , Pri ceto , N . J .

S E C RETARI E S .

— n S DR . G I . I8 8 . WILLIAM H ARMAL , New Haven , Con — CARMALT . 1 8 I DR . 9 . WILLIAM H , New Haven , Conn

— MALT . I8 DR . CAR 94 . WILLIAM H , New Haven, Conn — AL CARM T . 1 8 DR. . 97 WILLIAM H , New Haven , Conn — AL n I o o DR. A . CARM T . o WILLI M H , New Haven , Con — MALT 1 0 DR . CAR . 9 3 . WILLIAM H , New Haven , Conn — MALT n 1 0 DR . CAR . 9 7 . WILLIAM H , New Haven , Con — 1 1 0 DR . CARMALT . 9 . WILLIAM H , New Haven , Conn — f n 1 1 DR . . 9 3 . WALTER R STEINER, Hart ord , Con — f 1 1 6 DR . . 9 . WALTER R STEINER, Hart ord , Conn — f 1 1 DR . . 9 9 . WALTER R STEINER, Hart ord , Conn — f 1 2 2 DR . . 9 . WALTER R STEINER, Hart ord , Conn — f 1 2 DR . . 9 5 . WALTER R STEINER, Hart ord, Conn — f 1 2 8 DR . . 9 . WALTER R STEINER, Hart ord, Conn

T REAS URERS . B H . ST . . D . JO N ROOSA, New York City

H B . I . JO N S . LLINGS , Washington, D C

t . H . B . JO N S ILLINGS , Washing on , D C W H NE TON M . S AFFER, New York City . W H NE TON M . S AFFER, New York City . W H NE TON M . S AFFER, New York City . W H NE TON M . S AFFER, New York City . W H NE TON M . S AFFER, New York City . W H NE TON M . S AFFER, New York City . W H NE TON M . S AFFER, New York City .

FRANCIS W . PEABODY, Boston , Mass .

FRANCIS W . PEABODY, Boston, Mass .

FRANCIS W . PEABODY, Boston , Mass .

H . JO N E LANE, New Haven, Conn . B Y - LAWS OF THE C ONGRES S

AMERICAN P HYSIC IANS AND SURGEONS

1 .

This org aniz ation shall be known as the

OF I H AND CONGRESS AMER CAN P YSICIANS SURGEONS .

It shall be compose d Of national associations fo r th e promotion Of medical and allied science s .

3 .

n nn h o f n e t e t t . . It shall hold its s ssio s trie ially in ci y Washi g on, D C

4.

ffi o f ss R - A The o cers the Cong re shall be a P ESIDENT, VICE PRESIDENTS,

A T AND AN IV . SECRETARY, REASURER, EXECUT E COMMITTEE

5 .

R s be t E uti e t o f h e The P ESIDENT hall elec ed by the xec v Commit ee, which - x o i i He s e e at th e s s n Of th e n ss. shall be e fi c o a member . hall pr sid es io s Co g re

He shall deliver anaddress.

6.

‘ The PRESIDENTS Of th e participating societies shall be e x-o filc i o the VICE o f h ss PRESIDENTS t e Congre .

7 . The SECRETARY and the TREASURER Shall be e lected by the Executive Co m i - l f h m e e . S x i E tt They hall be e o fi c o members o t e xecutive Committee .

8.

Th e EXECUTIVE COMMITTEE shal l be composed o f one ( 1 ) member from each participating Society and said members shall be elected by the various a h n u u o n Socie ties t t e next a nual meeting s bseq ent t the Co gre ss . It shall be charg ed with all duties pertaining to th e organiz ation Of and ti n fo r n u e u t n o f Of s and prepara o the e s ing Congr ss , incl ding the elec io all ficer o f tt o f n ns a Commi ee Arra g eme t .

9.

The e xpenses o f the Cong ress shall be divided betwe en th e participating in Societies proportionto their membership .

Io .

The admission o f new associations to participate in th e Congre s s shall be un n us t o f V by a imo vo e the EXECUTI E COMMITTEE . MI N U T E S

The fourteenth triennial session O f th e Congress of American Physicians and Surgeons was held in th e Convention Hall Of th e n I nd 2 d 1 2 H n n . st a 8 t in t . C o Mayflower o el , Washi g o , D , May , 9 , t m t according to th e program me as ordered by th e Execu ive Com i tee . I n P M. st t to at 8 . The firs sessio was called order , Tuesday, May , - i F n Mc Ke nz Fo nt a . th V t . . e by e irst ice Preside , Dr A rbes Of Mo re l “ t t n nti o n Dr . Theobald Smi h he delivered his Preside al address The n ” Decline of Infectious Diseases and its Relationto ModernMedici e . This was followed by anaddress inhonor O f th e Semi-Centennial o f th e American Laryngologi cal Association by th e P resident o f that n B n n f n t . . r o t o Associa io , Dr D yso Delava New York Ci y , The n f n n n ” Fou ders o M o der Lary gology and Rhi ology . n h o w n t n P M O t e f llo i g day th e me e i g was called to order at . . h n n t e t . t . t to d by Preside , Dr Theobald Smi h The subj ec be co sidere “ was The Heart . Papers were read by Dr Haven Emerson Of a ni s t t o n E n m c t Columbi U ver i y , of New York Ci y , The co o ic Aspe s ” H rt H F t O f th R n t t t Of ea Disease ; Dr . omer . Swi f e ockefeller I s i u e “ R a t o n H rt in Infe c for Medical ese rch O f New York Ci y , The ea

t n . f h io Dr Paul D . White o t e Massachusetts Ge neral Hospital Of ” B t n o n Eff t t n o n h H n t e t a d . os o , The ec s of S rai ear ; Dr James “

B . H o f th e R a o n nt o n errick ush Medic l School , Chicago , Comme s th e eatm nt Tr e Of Heart Disease . These papers were d i scussed by

. a B . t t n f E . E . Dr dw rd P Car er of al imore , Dr Alfred Coh o New t - i G. Camb n l . R no f H n l O f York Ci y, Dr y obi so Nashv l e , Dr . e ry Sewa l n B . f F . n . . o t a d . De ver, Dr Louis ishop New York Ci y , Dr S A e n B t n L vi e of os o .

n n Adj our me t . X GUESTS OF THE CONGRESS

O CONGRES S OF AMERICAN PHYSICIANS AND SURGE N S .

OF 1 1 2 . REPORT TREASURER, JANUARY , 9 9

R P T ECEI S . Cash balance from previous treasurer u f h Assessments Of constit ent associations o t e Congress . Registrations Interes t on bank deposit

DISBURSEMENTS .

utt u t . T le , Moreho se Taylor ( reprin s , etc ) Rubber stamp Postage stamps

Paid by Dr . A . R . Shands Printer ’ s bill Printer ’ s bill ’ ’ Dr . Shand s secretary s salary u u Of t t n Clerks , B rea Regis ra io Postage Use o f lantern

: t u . Incidentals regis ration book, r bber stamp ; dup

e tc . checks , fo r u M . G . Thompson, clerical work treas rer z f n . . e t o V B Alvare , R por er Co g ress

u u l . T ttle , Moreho se Taylor ; programs and enve opes fl t May ower Ho el , electrician fu o f o f f Re nd overpayment registration to Dr . E . Rix ord

Total disbursements

n — o n n Of Bala ce on hand deposit in Savi g s Dept . The t n First Na ional Ba k, New Haven

Estimated cost O f publication o f Proceeding s o f Cong ress Estimated balance after payment fo r publication o f Pro c e e d ing s o f Cong r ess

Tr re r e asu . J . E . LANE, i ur Co ng re ss o f Am e r c an P hy si c ians and S g e o ns .

GUEST S OF THE CONGRES S .

BY V OF THE V IN ITATION EXECUTI E COMMITTEE.

u n- Mrri n e tte . n m S rgeo General W Irela d, U ited States Ar y . u n- E s . v . S rgeo General dward R Stitt , United State Na y u n- u nt u . u t t s . S rgeo General H g h S C mmings , U i ed S a e P blic Health Service M EM BERS OF THE CONGRESS xi

MEMBERS OF THE CO NGRES S .

* Members present are indicated by

O O O O AMERICAN PHTHALM L GICAL S CIETY .

Or ani z e 1 86 g d 4 .

V AND ACTI E MEMBERS ASSOCIATES .

. . t Dr Ellice M Alger, New York Ci y . * . . . n Dr A N Alling, New Haven, Co n . n . San Dr Ha s Barkan , Francisco, Cal . * . . . n Dr S J Beach , Portla d , Me . * u . Dr . Arth r J Bedell , Albany , N . Y .

Dr . George H . Bell , New York City .

Dr . James H . Bell , Richmond, Va . * Dr . William L . Benedict , Rochester , Minn . * Dr . Conrad Berens , New York City . * u Dr . Nelson M . Black, Milwa kee , Wis . * u Dr . E gene M . Blake , New Haven, Conn . r Dr . James Bordley , J . , Baltimore , Md . * Dr . H . H . Briggs , Asheville , N . C . * . n . Dr . E V . L . Brow , Chicago , Ill * E un . Dr . William . Br er, Cleveland, Ohio

. . u Dr . H D Br ns , New Orleans , La .

u r . Dr . A . E . B lson, J . , Fort Wayne , Ind * . u . . Dr John W . B rke , Washington, D C * u . Dr . W . K . B tler , Washington, D C . * Dr . W . Gordon M . Byers , Montreal , Canada . * z u . Dr . F . Phini y Calho n, Atlanta , Ga

Dr . F . P . Capron , Providence , R . I .

Dr . J . T . Carpenter, Philadelphia, Pa . * u n . Dr . B rto Chance , Philadelphia, Pa

Dr . H . B . Chandler, Boston , Mass . * M u O . Dr . J . W . Charles , St . Lo is , * Dr . E . W . Clap , Boston, Mass . * Dr . C . A . Clapp , Baltimore , Md .

u u . Dr . C . F . Clark, Col mb s , Ohio * n . Dr . Martin Cohe , New York City * f n . Dr . Al red Cowa , Philadelphia , Pa * Dr . G . S . Crampton , Philadelphia, Pa . * Dr . George H . Cross , Chester , Pa . M u O . Dr . R . J . C rdy, Kansas City,

u . Dr . Colman W . C tler , New York City E t . Dr . A . . Davis , New York Ci y

. . E Dr David N Dennis , rie , Pa . M EM BERS OF THE CONGRESS

n e . ss. Georg S Derby, Bosto , Ma E n n t . Oscar Dodd, va s o , Ill

. t William B Doherty, New York Ci y . nn E . E tt C . lle , Memphis , Te . E n MO . t u . St. u Ar h r Ewi g, Lo is , n t e . T . H . Fe on, Philad lphia, Pa n u E . C . Fi lay, Havana, C ba . ' Finn Pr n O o o . William C . , De ver, C l LOS n Carl Fisher , A geles , Cal .

George F . Fiske, Chicago, Ill . rid e nbe r Percy F g , New York City . Fri d e nwald e . H . , Baltimore , Md Fri d e n ald n . e w t . Jo as S , Bal imore , Md

. . u s. E L Goar, Ho ston , Texa

H . S . Gradle, Chicago Ill . n n U M St . O . Joh Gree , LO IS,

n . . . t . L S Greene , Washing o , D C n o o n t s . Alle Greenw d , Bos o , Mas

n . J . Milto Griscom, Philadelphia , Pa

n u n . Henry C . Hade , Ho sto , Texas

e u . F . H . Haessl r , Milwa kee , Wis

nn ss. m . ut Willia D Hall , So h De is , Ma

e z . D . F . Harbridg , Phoenix, Ari M . St . u s O . William F Hardy, Lo i ,

ass . David Harrower, Worcester , M

n . . N . D . Harvey, Provide ce , R I

Parker Heath , Detroit , Mich .

E tt u . dward B . Heckel , Pi sb rgh, Pa

s . . Charle R Heed, Philadelphia , Pa

E n . mory Hill , Richmo d , Va

n t . Ward A . Holde , New York Ci y

T . B . Holloway, Philadelphia, Pa.

E r . . . E . Holt, J , Portland , Me

z t ss. W . F . Hol er , Worces er , Ma

. St . u . Harvey J Howard, Lo is , Mo

u nt . L cien Howe, Belmo , Mass

E E t n . . . Jack, Bos o , Mass

E n o o . dward Jackso , Denver , C l

n . . P . C . Jameso , Brooklyn, N Y

n n . . . e J Wilkinso Jerv y , Gree ville , S C

n n f . B . R . Ken o , Nor olk, Va

Be n t t . Wit Key , New York Ci y

n t . Clarence King, Cincin a i , Ohio

n n t . Ar old K app , New York Ci y

t . Carl Koller , New York Ci y n Ko llo c k t . . Charles W . , Charles o , S C MO . St . u . Harvey D Lamb, Lo is ,

n . t . t . Rober S Lamb, Washi g on, D C MEMBERS OF TH E CONGRESS xiii

* E . t Dr . W . Lamber , New York City . * . . . n Dr W B Lancaster , Bosto , Mass . * . . . a Dr H M Langdon, Philadelphia, P . t J . C . Les er , New York City .

. 1 C0 0 . George F Libby, Denver , n . . n J A Lippi cott , Nice, Fra ce .

. . n R G Loring , Bosto , Mass .

D . B . Lovell , Worcester , Mass .

. . n W H Lowell , Bosto , Mass . L . . ue d d e . u MO W H , St Lo is , . Mc Co o l Joseph L . , Portland , Ore . MGui re un . c n e . H ter H , Wi chest r , Va MK . . c e e n S H , Montreal , Ca ada .

A . L . Macleish, Los Ang eles , Cal .

. . u F W Marlow, Syrac se , N . Y . n . . t . G H Mathewso , Mon real , Canada

C . H . May , New York City . s r H . S . Mile , B idgeport , Conn . n . n . J Lancelot Mi or, Memphis , Te n ’ O Brie n . . o . C S , Iowa City, I wa hl n . O Joh H y , Brooklyn , N . Y .

. . t W R Parker , De roit , Mich .

u . t L ther C Pe er , Philadelphia , Pa . P fin st u Adolph O . g , Lo isville , Ky .

W . Campbell Posey , Radnor, Pa . M . St . u O . L . T Post, Lo is , M t r . S t. u O . M . H . Pos , J , Lo is , n n nn A . D . Pra g e , Rochester , Mi .

n us . Brow P ey , Chicago , Ill n uac ke nbo ss Alexa der Q , Boston, Mass .

Mc lune ff . C y Radcli e, Philadelphia , Pa

Warren S . Reese , Philadelphia , Pa .

. 0 . . G Ring, Philadelphia , Pa

t . William H . Rober s , Pasadena , Cal

u t . D nbar Roy, A lanta , Ga

u . Calvin C . R sh , Johnstown , Pa

u . . John D . R shmore, Brooklyn, N Y

u s . Bernard Sam el , New York City

t t . Rober Sattler , Cincinna i , Ohio

utt . A . C . Sa er , Philadelphia, Pa

u . . H nter W Scarlett , Philadelphia, Pa

S c hne id e m an . T . B . , Philadelphia, Pa

. . e or ity . M J Schoenberg, N w Y k C

z . G . E . de Schweinit , Philadelphia , Pa

n . P . N . K . Schwe k, Philadelphia , Pa M n . u O . William E . Shaha , St Lo is ,

C . E . G . Shannon , Philadelphia , Pa .

n nn . Joh R . Sha on , New York City x i v M EM BERS OF TH E CONGRESS

. . t . Dr Francis W Shine , New York Ci y

. . M 0 O J F Shoemaker , Clayton, . M . . u O . William A Shoemaker , St Lo is ,

William T . Shoemaker , Philadelphia, Pa . E u . A . Sh mway, Philadelphia , Pa .

t . Dorland Smith, Bridgepor , Conn f E . T . Smith, Hart ord, Conn .

Albert C . Snell , Rochester , N . Y .

F . M . Spalding, Boston, Mass . u Edward Stieren, Pittsb rgh , Pa . u William Tar n, Baltimore , Md .

- Lewis H . Taylor , Wilkes Barre , Pa.

Edgar S . Thomson, New York City .

James Thoring ton, Philadelphia , Pa . n Fred T . Tooke , Mo treal , Canada . M . u O . Charles W . Tooker , St Lo is ,

E . Torok, New York City .

H . H . Tyson, New York City . t Derrick T . Vail , Cincinna i , Ohio .

C . A . Veasey , Spokane , Wash .

ff . F . H . Verhoe , Boston , Mass n Henry Wagener, Rochester , Min . f n F . L . Waite , Hart ord , Con . ff Cli ord B . Walker, Los Angeles , Cal .

. E . . J Weeks , New York City

t . Walter B . Weidler , New York Ci y

. . t . C D Wescot , Chicago , Ill n Joh M . Wheeler , New York City .

J . A . White , Richmond , Va .

Lloyd B . Whitham, Baltimore , Md .

W . H . Wilder , Chicago , Ill . * Dr . Carl Williams , Philadelphia , Pa .

. s . Edward R William , Boston, Mass

William H . Wilmer , Baltimore , Md .

. tt roo ly , . Y . J Sco Wood , B k n N ’ M uff . u O . F . E . Woodr , St Lo is ,

Alan C . Woods , Baltimore , Md .

o . Hiram Wo ds , Baltimore , Md

H . W . Wooton , New York City .

u Yud kin n nn. Arth r , New Have , Co

Ze ntm a e r . William y , Philadelphia , Pa

H ONORARY MEMBER .

Carm alt n nn. Dr . William H . , New Have , Co

M EM BERS OF TH E CO NGRESS

E n dward B . De ch, New York City .

. . nni o o F L De s , Colorado Springs , C l . n . . t Joh K M Dickie, Ot awa , Canada . E E u rnest . Doble, Q incy, Mass . n r . . . e . J W Dow ey, J , Baltimor , Md

. u n Dana W Dr ry , Bosto , Mass .

u . u Arth r B D el , New York City .

James G . Dwyer, New York City . n . t . . Wells P Eagle o , Newark, N J n E n . s . Fra cis P mer o , Boston , Mass u C rtis C . Eves , Philadelphia, Pa . n uff Joh F . Fairbairn, B alo, N . Y . un n C . B . Fa ce, Bosto , Mass . n n n . t n Ralph A Fe o , Portla d, Orego . e L wis Fisher , Philadelphia , Pa .

s . George F . Fi ke , Chicago , Ill

E . P . Fowler, New York City . ri e d e nwald t e Harry F , Bal imor , Md . n Isidore Fries er, New York City . n E . B . Gleaso , Philadelphia , Pa . i t . Perry Goldsm h, Toronto , Canada u Max A . Goldstein, St . Lo is , Mo .

u . Thomas H . Halsted , Syrac se , N Y .

n . Philip Hammond , Bosto , Mass

Thomas J . Harris , New York City .

n . William H . Haski , New York City

Frederick T . Hill , Waterville , Me .

u Ho lin e r . Jacq es g , Chicago, Ill

Frank T . Hopkins , New York City .

u t . Lester M . H bby , New York Ci y i . . iam , lorida . J M Ingersoll , M F

Frederick L . Jack, Boston, Mass .

n s n . Isaac H . Jo e , Los A geles , Cal

. . hiladelphia , a . J C Keeler , P P

nn n f . B . R . Ke o , Nor olk, Va

n . Philip D . Kerriso , New York City

an . Frank B . Kistner , Portl d , Oregon

John C . Lester , New York City .

u LOS . E gene R . Lewis , Angeles , Cal

t . Rober Lewis , New York City nn H . I . Lillie , Rochester , Mi . M n O . James E . Loga , Kansas City ,

Mc Auli . . e George B , New York City

M aW . . . c C James F , Watertown , N Y

n Mc Co t . Joh y , New York Ci y

Mc Ke rno n t . James F . , New York Ci y

Mc Kim m ie t . . O . A . M . , Washing on , D C M EMBERS OF THE CONGRESS xvi i

* z Dr . Philip E . Melt er , Boston, Mass . * f Dr . Cli ton L . Miller , Richmond , Va . M l . . e dfi e d . Dr Henry L Morse , , Mass * Dr . Harris P . Mosher , Boston, Mass . * n Dr . Horace Newhart, Min eapolis , Minn .

Dr . Francis R . Packard , Philadelphia , Pa . * n . Dr . Joh R Page , New York City .

Dr . Wendell C . Phillips , New York City . * Dr . Norval H . Pierce , Chicago, Ill . * . . t . Dr Charles T Por er, Boston , Mass r Dr . George H . Powers , J . , Boston, Mass . * Dr . John B . Rae , New York City . * Dr . B . Alex . Randall , Philadelphia , Pa . * n uff Dr . W . Scott Ren er , B alo , N . Y .

Dr . George L . Richards , Fall River , Mass . * Dr . Charles W . Richardson, Washington, D . C . * s . Dr . Walter Robert , Philadelphia , Pa * h n . Dr . Jo n A . Robinso , New York City * MO . E . u u Dr W . Sa er , St . Lo is , .

n . . . ur e u s Dr T La anc Sa der , New York City n f . t . Dr Gra Sel ridge, San Francisco , Cal

u . George E . Shamba g h , Chicago, Ill

u . . Warren S . Shatt ck, Brooklyn, N Y h l . u . S ur B rt R y , Detroit , Mich f E . Terry Smith , Hart ord , Conn . i J . M . Sm th , New York City . Ma u n . . c C e h S Smith , P iladelphia, Pa

D . Campbell Smith , Boston, Mass . nn t . Rober So enschein , Chicago , Ill

. . u o o . F R Spencer, Bo lder , C l n M o u O . Selde Spencer , St . L is ,

n . Frankli M . Stephens , New York City

n . . u t Joseph A St cky , Lexing o , Ky

a . u n t . Edw rd Blair S tphe , Morris own , N J - Lewis H . Taylor , Wilkes Barre , Pa .

. v . H Marshall Taylor, Jackson ille , Fla

J . J . Thomson , Mt . Vernon , N . Y .

George L . Tobey , Boston , Mass .

. t . Harold G Tobey, Bos on, Mass i s . . Harri H Vail , Cincinnati , Oh o n i . V o slawsk t . A tonie P y , New York Ci y

D . Harold Walker , Boston, Mass .

Joseph A . White, Richmond , Va .

n . t . Leo E White , Bos on , Mass

n t . Fred Whiti g , New York Ci y

n n . Joh Gordon Wilso , Chicago , Ill

i n . E . Dav d . S Wishart , Toro to , Canada xviii M EMBERS OF THE CONGRESS

HON M ORARY EMBERS .

u t Dr . Gorham Bacon , Yarmo thpor , Mass .

Dr . John S . Fraser , Edinboro, Scotland . u Dr . Stacy R . G ild , Baltimore, Md .

o . . n Pr f Dayton C Miller , Clevela d, Ohio .

o . . . Pr f G H Parker , Cambridge , Mass . u Dr . Jonathan S . Pro t, Fishkill , N . Y . u Dr . Sam el Theobald , Baltimore, Md . M r . . R L . Wegel , New York City .

M SENIOR EMBERS .

r t . Hen y A . Alderton, Palo Al o , Cal

. t . Frank J Blodgett , New York Ci y l n . Frank i P Capron, Providence, R . I . E J . B . merson, New York City .

George W . Hale , Nashville , Tenn .

David Harrower , Worcester , Mass .

N . Darrell Harvey , Providence , R . I .

u . Erast s E . Holt , Portland , Me

u . Thomas H bbard , Toledo, Ohio

t . Richard Jordan, New York Ci y

t . David B . Lovell , Worces er , Mass

t . . Rober C Myles , New York City n n . . 0 . He ry Reik, Trento , N J

u . . H ntington Richards , Concord, N H n Henry W . Ring, New Haven, Con .

n . u . John D . R shmore , Brookly , N Y

VVh e e lo c k . . Edward , Waverly , N Y

AMERICAN NEUROLO GICAL AS S OCIATI ON . n r anz e u e 1 8 . O g i d J , 7 5

ACTIVE MEMBERS .

n t . Isador Abrahamso , New York Ci y

Herman M . Adler, Chicag o, Ill .

n . . Edward B . A gell , Rochester , N Y

LaSalle u t an . . Archamba l , Alb y, N Y

James B . Ayer , Boston, Mass .

Charles Bagley, Baltimore , Md .

s . Percival Bailey, Boston, Mas nn St. u . Charles R . Ball , Pa l , Mi

L ll . e we s . y F Barker , Baltimore , Md

Ann . t . Alber M Barrett , Arbor, Mich M EM BERS OF THE CONGRESS x i x

Ba sso e . Peter , Chicago, Ill

Christopher C . Beling, Newark, N . J . t E . Bates Block, A lanta, Ga . E n arl D . Bo d, Philadelphia, Pa . u Sam el Brock, New York City . zud Sanger Brown, , New York City .

William Browning, Brooklyn, N . Y . u Albert C . B ckley , Philadelphia, Pa . u Michael A . B rns , Philadelphia , Pa . u C . B . B rr , Flint , Mich . u Charles W . B rr, Philadelphia, Pa . n . s . Charles M Byr e , Baltimore , Md

W . B . Cadwalader , Philadelphia , Pa .

Carl D . Camp , Ann Arbor, Mich . Mac fi . e C Campbell , Cambridge , Mass .

. u MO Given Campbell , St Lo is , . u Casam a Lo is j or, New York City .

u . Archibald Ch rch , Chicago , Ill

L . Pierce Clark, New York City .

Stanley Cobb , Boston, Mass . n Leo H . Cornwall , New York City .

t . Henry A . Cotton , Tren on , N J .

u . Joseph W . Co rtney , Boston, Mass

n . Bronso Crothers , Boston, Mass

u . Harvey C shing, Boston, Mass

Charles L . Dana , New York City .

Walter E . Dandy , Baltimore , Md .

o . L yal Davis , Chicago , Ill

Thomas K . Davis , New York City . X u . Francis . Derc m , Philadelphia, Pa f n nn f . Allen R . Die endor , New Have , Co u Theodore Diller , Pittsb rgh Pa .

r . n i . Hen y H Donaldso , Philadelph a , Pa

Do m an . . w Charles E , Atlanta, Ga

n u o o . Fra klin G . Eba gh , Denver , C l ’ Bufialo John L . Eckel , , N . Y . E t . Charles A . lsberg , New York Ci y F avill . John , Chicago , Ill

Temple Fay , Philadelphia , Pa .

z . Charles H . Fra ie r , Philadelphia, Pa

t . Walter Freeman , Washing on , D C .

u . . Eman el D Friedman, New York City

n . Sherman F . Gilpi , Philadelphia , Pa

u . Joseph H . Glob s , New York City

S . Philip Goodhart New York City .

Hermon C . Gordimer, Troy , N . Y .

f . Al red Gordon , Philadelphia , Pa

Francis Clark Grant , Philadelphia , Pa . M EMBERS OF TH E CONGRESS

. . u William W Graves , St Lo is , Mo .

Donald Gregg, Wellesley, Mass .

Menas S . Gregory , New York City . n Morris Grossma , New York City .

George W . Hall , Chicago , Ill .

n . Fra k K Hallock, Middletown, Conn .

Ralph C . Hamill , Chicago , Ill . i n n t u . n. Ar h r S Ham lto , Min eapolis , Min

S . . t u nn Ernest M Hammes , Pa l , Mi .

Graeme Hammond, New York City . u n Sam el T . Harvey , New Haven , Con . I" I . George B . Hassin , Chicago, u u Lo is Ha sman, New York City . ’ C . Floyd Haviland, Ward s Island , New York City .

t . William Healy , Bos on , Mass n an . t . Herm H Hoppe , Cinci na i , Ohio ax t Ho rr n . Gilber , Bosto , Mass

u . William Ho se, Portland, Ore

u r . H be t S . Howe , New York City n un i t . Edward L vingsto H , New York City u J . Ramsay H nt , New York City .

u . L OS . Sam el D Ingham, Angeles , Cal

George W . Jacoby , New York City . llifi e e . Smith Ely J , New York City nn . n . William A Jones , Min eapolis , Mi

Foster Kennedy, New York City . K hn r e sc e . Moses , New York City ’

i . Georg e H . K rby, Ward s Island , New York City n n . Simo P . Kramer , Cincin ati , Ohio u Walter M . Kra s , New York City . n . n . Frank W Langdo , Cincin ati , Ohio

t . Frederic H . Leavit , Philadelphia , Pa u Sam el Leopold , Philadelphia , Pa . u u u w . Seymo r De itt L dl m, Philadelphia , Pa n Mac P h e rso n Do ald J . , Boston, Mass .

n . c . Da iel J Mc arthy , Philadelphia , Pa M n l c Co ne l . J . W . , Philadelphia , Pa

Mc Ke nd re e . Charles A . , New York City

MKinl . . . c e n e J C y , Mi n apolis , Minn

n . . s n Henry G Mehrte , San Fra cisco , Cal

u n . . H go Mella , Long Isla d , N Y f t . Adol Meyer , Bal imore , Md

Charles K . Mills , Philadelphia , Pa .

Harry W . Mitchell , Warren , Pa .

. ss . William J Mixter , Boston , Ma

nn. Frederick P . Moersch , Rochester , Mi

u . r nn Ang s W Mo rison , Minneapolis , Mi . u u A brey T . M ssen , Baltimore , Md . M EM BERS OF TH E CONGRESS xxi

s . Dr Abraham Myer on, Boston, Mass ' Nafi z i e r an al . S C . Dr . Howard C g , Francisco, * u t u u Dr . Sam el T . Or on, Col mb s , Ohio . O snato Dr. Michael , New York City . * . i Dr Irv ng H . Pardee, New York City .

t nn. Stewar Paton , New Haven, Co u H gh T . Patrick, Chicago , Ill .

Clarence A . Patten, Philadelphia, Pa . P e nfie ld Wilder G . , New York City .

Frederick Peterson , New York City .

Lewis J . Pollock, Chicago, Ill .

Charles S . Potts , Philadelphia, Pa.

e . G orge E Price , Spokane , Wash .

Morton Prince , Boston, Mass .

. u uff . James W P tnam, B alo, N Y . u FOX A sten Riggs , Stockbridge , Mass .

Henry Alsop Riley , New York City .

n . u t . Coli K R ssel , Mon real , Canada

Bernard Sachs , New York City .

u . Ernest Sachs , St . Lo is , Mo

n . . Sa Walter F Schaller, Francisco , Cal M u O . Sidney I . Schwab , St . Lo is , u La rence Selling, Portland, Ore .

E . ff u . . dward A Sharp , B alo, N Y n Walter Shelden, Rochester , Min . u H . Do glas Singer , Chicago, Ill .

. t . Harry C Solomon , Bos on, Mass

William G . Spiller , Philadelphia , Pa.

M . Allen Starr, New York City .

n . Byro Stookey, New York City

“ u Ne w t . Israel Stra ss , York Ci y

Edward A . Strecker , Philadelphia, Pa . f Al red S . Taylor , New York City .

Edward W . Taylor , Boston, Mass .

D u as . t . o gl A Thom, Bos on, Mass

n . hn . t Jo J Thomas , Bos o , Mass

n Ne w . Frederick Til ey, York City

t . Walter Timme, New York Ci y

u . Beverley R . T cker , Richmond , Va r Hen y R . Viets , Boston , Mass .

William K . Walker, Phoenixville, Pa .

n n . . t George A Wa erma , Bosto , Mass

Israel S . Wechsler, New York City .

W i n . . e se bur Theodore H g , Philadelphia , Pa

. t . . William A White , Washing on , D C

George Wilson , Philadelphia , Pa .

n . Nathaniel Winkelma , Philadelphia, Pa u W lf hn . o so an . J lian M , S Francisco, Cal xxii M EMBERS OF T HE CONGRESS

f Dr . David I . Wol stein, Cincinnati , Ohio . * Dr . Henry W . Woltman, Rochester , Minn . * n . Dr . A drew H Woods , Peking, China . * i Yaw e r Dr . Nathan el S . g , Philadelphia , Pa. * . E . Dr dwin G Zabriskie, New York City .

ADJ UNCT MEMBERS .

u Dr . Sam el W . Hamilton, White Plains , N . Y .

. . n Dr Goldwin W Howland, Toronto, Ca ada . * u Ma R be r . c o t Dr R ssell , New York City . * n f Dr . Clarence P . Ober dor , New York City . * . t Dr Theophile Raphael , De roit, Mich .

AS SOCIATE MEMBERS .

- Dr . Andre Thomas , Paris , France .

Dr . Max Bielschowsky , Berlin, Germany . M . . . u O Dr Malcolm A Bliss , St Lo is , . n n u u t . Dr . E ge e D . Bo d ran , Mobile , Ala

. . u t . Dr J Arth r Booth, New York Ci y u Dr . Edward N . Br sh , Baltimore , Md . u n Dr . William N . B llard, Bosto , Mass . u Dr . Henri Cla de , Paris , France .

Dr . Richard S . Dewey, Pasadena , Cal . u Dr . Thomas S . Dowse , Exmo th , England . u u " u z n Dr . A g ste Fore , Va d, Swit erla d . M . o u O Dr . Frank R . Fry , St L is , .

u n . D r . Georges G illai , Paris , France n Dr . Ross G . Harriso , New Haven, Conn .

Gu . Dr . y Hinsdale , Hot Springs , Va

o n . D r . G rdo Holmes , London , England h Ku . Dr . Sidney , Chicago , Ill

d . . Dr . E ward B Lane , Boston, Mass

n . Dr . Jea Lhermitte , Paris , France

M Bri . . c d e Dr James H . , Pasadena , Cal

M K nnan u . . . c e Dr T . M T . , Pittsb rgh , Pa

u u t . D r . Otto I . Marb rg , Vienna, A s ria u u n Dr . G . Marinesco , B carest , Ro ma ia. Ki n n o suk . . e u Dr Mi ra, Kanda, Tokyo f . uf u . . Dr Bronislaw On , R ther ord , N J

. u . D r Walter E . Pa l , Boston, Mass

o o . Dr . Howell T . Pershing , Denver , C l - n u . S ir James P rves Stewart, London , Engla d

n . . t n n D r S ephe Walter Ra so , Chicago , Ill n n . u . . Eu s Dr C . ge e Rig g , St Pa l , Min

u . Dr . G . I . Rossolimo, Moscow, R ssia

M EMBERS OF THE CONGRESS

u s H . C . B rges , Montreal , Canada .

u . u C rtis F B rnam , Baltimore , Md . N e w . William Edgar Caldwell , York City

Alexander M . Campbell , Grand Rapids , Mich .

. t u . Thomas B Carroll , Pi tsb rg h, Pa

w . e . De itt B Casler, Baltimor , Md f n . t u Sid ey A Chal an , Pittsb rgh , Pa. N n r . e w Charles Gard er Child, J , York City . i n n n . t a . Walter W Ch pma , Mo real , C ada M . St. u s O Harry S Crossen, Lo i , . u t n Carey C lber so , Chicag o, Ill . u n Thomas S . C lle , Baltimore, Md .

u . u Arth r H C rtis , Chicago, Ill . f . t E st . William C Dan or h , van on, Ill n u e Wi s. Carl He ry Davis , Milwa ke , h D Le o se B . e e J p , Chicago, Ill . n Robert L . Dickinso , New York City . u E f M S . u O t s . H go hren est , Lo i ,

Lillian K . P . Farrar, New York City .

Palmer Findley , Omaha, Neb . Fo ulkro d Collin , Philadelphia , Pa. n N . . e w t Robert T Fra k, York Ci y

n . n n t . Joh R Fraser, Mo real , Ca ada n MO . u s . George Gellhor , St Lo i ,

. u Bqal . O . . F G Goldsboro g h , , N Y n n s . t . Jame R Goodall , Mo real , Ca ada n . s William P Graves , Bosto , Ma s .

o e t eane . N bl Sproa H y, Chicag o, Ill n n William B . Hendry, Toro to, Ca ada.

. t . William P Healy , New York Ci y t t Bar on Cooke Hirs , Philadelphia , Pa . n . t . Frederick C Holde , New York Ci y

u . t . R dolph W Holmes , Universi y , Va

n u . . u s Raleigh R H gg i , Pittsb rgh, Pa Gu L R u e o t . y y H nner , Bal imore, Md u Henry Talbot H tchins , Boston , Mass . r o o C . B . Ingraham , J . , Denver , C l .

n . Frederick C . I rving, Bosto , Mass E Floyd . Keene , Philadelphia, Pa.

Edward L . King , New Orleans , La . E uff James . King, B alo , N . Y .

Ko sm ak t . George W . , New York Ci y

n . t . Herber M Little , Montreal , Ca ada

z n . Jennings C . Lit enberg, Minneapolis , Mi n n an . S . Frank W Ly ch , Francisco , Cal M l c Ginn . John A . , Philadelphia , Pa

Franklin H . Martin , Chicago , Ill . nn . st . James C Masson , Roche er , Mi MEMBERS OF THE CONGRESS X X V

* Dr . Harvey B . Matthews , Brooklyn, N . Y . * ff Dr . C . Je Miller, New Orleans , La . * . . t . . Dr G Brown Miller, Washing on , D C

Dr . William Horace Morley , Pontiac , Mich .

u . Dr . Arth r H Morse, New Haven, Conn . * k Dr . Fran lin S . Newell , Boston, Mass . * n Dr . William R . Nicholso , Philadelphia, Pa .

Dr . George H . Noble , Atlanta, Ga . * Dr . Charles C . Norris , Philadelphia, Pa . * Dr . Richard C . Norris , Philadelphia, Pa . * ak . Ov Dr Emil N , Baltimore , Md . n . . t Dr Frank A Pember o , Boston, Mass . A . u nn Dr Re ben Peterson, Arbor , Mich . * u . Dr . Edm nd B Piper , Philadelphia , Pa . * . n Dr John Osbor Polak, Brooklyn, N . Y . * Dr . Reginald M . Rawls , New York City . * Dr . Edward H . Richardson, Baltimore, Md .

. n u Dr Isidor Clinto R bin, New York City . u Dr . M . Pierce R cker , Richmond , Va .

. u n . Dr Stephen R shmore, Bosto , Mass * Dr . John A . Sampson, Albany, N . Y . * . u n Dr Edward A . Sch man , Philadelphia , Pa .

. . t . Dr William A Scot , Toronto, Canada * . z . u Dr Otto H . Schwar , St Lo is , Mo .

Dr . Richard R . Smith , Grand Rapids , Mich . f Dr . Al red B . Spalding, San Francisco , Cal . * Dr . William Stephen Stone, New York City .

. M . u u O . Dr Frederick J Ta ssig, St . Lo is , * Dr . Howard C . Taylor, New York City .

Dr . Herbert Thorns , New Haven, Conn . * . ux Dr Norris W . Va , Philadelphia , Pa . n . Vi e be r Dr Hiram g , New York City . * Dr . George Gray Ward , New York City . * Dr . Benj amin P . Watson, New York City . * Dr . J . Whitridge Williams , Baltimore , Md . * Dr . Karl M . Wilson, Rochester , N . Y .

H O ONORARY FELL WS .

William E . Ashton , Philadelphia , Pa .

J . Montgomery Baldy, Devon, Pa .

. t . Hermann J Bold , New York City u Walter L . B rrage , Brookline , Mas s . f Henry T . By ord , Chicago , Ill . t Clemen Cleveland, New York City .

Henry C . Coe , New York City .

. u Andrew F C rrier , Mt . Vernon , N . Y .

a . t to s Fr ncis R Davenpor , Bos n , Mas . xxvi M EMBERS OF T HE CONGRESS

. E r d ard . a i s . . D w P D v , Princeton , N J

. Emilius u e Dr Clark D dl y, Chicago, Ill .

Dr . James C . Edgar , New York City .

Dr . Willis E . Ford, Utica, N . Y .

. GO iIe Dr J Riddle , New York City .

. . t Dr Charles M Green, Bos on, Mass .

. f Dr Phineas H . Ingalls , Hart ord , Conn .

. Dr Howard A . Kelly, Baltimore, Md . u Dr . Cyr s A . Kirkley, Los Angeles , Cal .

. . Dr Henry P Newman, San Diego , Cal .

. s . Dr Charle P Noble, Philadelphia, Pa .

. t Dr Edward Reynolds , Bos on, Mass .

. u n D r H nter Robb , Wi chester , Mass .

. . n n Dr William L Richardso , Bosto , Mass .

. . uns Dr Clarence J Webster , Shediac , New Br wick.

. . u D r Frank F Simpson, Spartansb rg, S . C .

. . LOS Dr W Francis Wakefield, Gatos , Cal .

FOREIGN FELLOWS .

. E Blair W Bell , Liverpool , ng land . n J . Amedee Doleris , Paris , Fra ce . n I n Thomas Watts Ede , London , W . . , Engla d . K d e rnath u e tt . Das , Calc a, India u J . M nro Kerr , Glasgow, Scotland . u u Ste instr 2 n A g st Martin, Freiherr vom , Germa y . n W . Nagel , Berlin, W . 57, Germa y .

n . Herbert R . Spe cer, London, England ffi r T u e . Th . , Paris , France

AMERICAN DERMATOLOGICAL AS S O CIATI ON .

r anz e S e e mbe r 1 8 6 . O g i d p t , 7

M ACTIVE ME BERS .

San tt . Harry Evere Alderson, Francisco, Cal n u r . Sam el Ayres , J , Los A geles, Cal .

t t . Andrew Por er Biddle , Detroi , Mich

' f u n t . Frederick Stan ord B r s , Bos on, Mass n nn ut . John B ler , Mi neapolis , Mi

t n . Ernes Dwight Chipma , San Francisco , Cal n Harold N . Cole , Clevela d , Ohio . n tt . William Thomas Corle , Clevela d , Ohio

ru h fie ld San a . . C tc Earl D , Antonio , Tex s

e w u . Georg De itt C lver, San Francisco , Cal

Charles N . Davis , Philadelphia, Pa . M EMBERS OF THE CONGRESS xxvi i

* . t . M u O . Dr Rober Hill Davis , St Lo is ,

. . MO Dr Charles C Dennie, Kansas City , . * . tt Dr Joseph Alexander Ellio , Charlotte, N . C . n n n . e e e . M u O . Dr Martin F y E g ma , St Lo is ,

. u Dr Clark W . Finner d, Chicago, Ill . * . . t u Dr Harry R Foers er, Milwa kee , Wis . * . tt u Dr O o Hottinger Foerster, Milwa kee , Wis . * Dr . Howard Fox , New York City . * Dr . J . Frank Fraser , New York City .

n . . u Dr Charles D . Freema , St Pa l , Minn . LOS Dr . Kendal Frost , Angeles , Cal . * n . . nn Dr William H Goeckerma , Rochester, Mi . * nn Dr . Herma Goldenberg, New York City . u n n . . s Dr Arth r M Gree wood , Bosto , Mas .

n n . u MO Dr . Joseph Gri do , St Lo is , . * Gu u Dr . William Harvey y , Pittsb rgh , Pa . * n z n . t Dr Henry Honeyma Ha e , Washing on, D . C . * n Dr . Walter J . Highma , New York City .

Dr . Ralph Hopkins , New Orleans , La . * Dr . Harry G . Irvine , Minneapolis , Minn . * Dr . Robert C . Jamieson, Detroit , Mich . * Ha h r Ann rt e . Dr . L Keim, Arbor , Mich . * t Dr . Lloyd W . Ketron, Bal imore , Md . n Dr . Lyle Boyle Kingery, Portla d , Ore .

e u . Dr . Jerom Kingsb ry, Philadelphia, Pa * - Dr . David King Smith, New York City . * Klaud e r n O . . t t Dr Joseph Victor , Toron o, , Canada . * z Dr . Frank Cro er Knowles , Philadelphia , Pa . * Gu n t . Dr . Clarence y Lane, Bos o , Mass * n nn Dr . Joh E . Lane , New Haven, Co . Li e be rth al Dr . David , Chicago, Ill . * Dr . Edward D . Lovej oy , Los Angeles , Cal . * n Mc B rid e MO Dr . William Lin Kansas City, . * Mc Ewe n Dr . Ernest Lewis , Chicago , Ill . * Mac ke e Dr . George Miller , New York City .

Edward R . Maloney , New York City .

u o o . Arth r Jackson Markley , Denver , C l

fi r . e e u . J y C Michael , Ho ston , Texas E n Henry . Michelso , Minneapolis , Minn . a . S n al C . Hiram E Miller , Francisco,

t . James Herbert Mi chell , Chicago, Ill an u S . Do glass William Montgomery , Francisco, Cal M u O . William Hewson Mook, St . Lo is ,

Howard Morrow, San Francisco , Cal .

u u u t . . Lo is B rgh Mo n , Albany, N Y ’

L ar . u . O e Pa l A y , Rochester , Minn

Edward A . Oliver , Chicago , Ill . * E e t . Dr . verard Lawrence Oliv r , Bos on , Mass xxvii i M EMBERS OF THE CONGRESS

* . u Dr Oliver Sam el Ormsby, Chicago , Ill . * n . . uff Dr Earl D Osbor e , B alo, N . Y . * - . . n u . Dr V Pardo Castello, Hava a , C ba * . . Dr Isaac R Pels , Baltimore , Md . * P lli z e r . u o t Dr Sigm nd , New York City . * u Dr . William Allen P sey , Chicago , Ill . u Ra o li . u u v Dr A g st s g , Cincinnati , Ohio . * Dr . Isadore Rosen, New York City . u Dr . E . Wood R ggles , Rochester , N . Y . a n in . S te ste Dr . David L , New York City . f S c h ale k Dr . Al red , Omaha , Neb . * Dr . Jay Frank Schamberg, Philadelphia, Pa . * . z t Dr Hans Jorgen Schwart , New York Ci y . u Dr . Francis E gene Senear , Chicago , Ill . i r Sh e lm e . Dr . Jesse B . , Sr , Dallas , Texas . * Dr . C . Morton Smith, Boston, Mass . * u Stillians Dr . Arth r W . , Chicago, Ill . * Dr . John H . Stokes , Philadelphia , Pa . * M . u t . . t O D r Richard L S t on, Kansas Ci y,

u z n. Dr . Sam el Sweit er , Minneapolis , Min * Dr . Harvey Parker Towle , Boston , Mass . * k . Dr . Henry Roc well Varney , Detroit , Mich * Wallh ause r Dr . Henry J . F . , Newark, N . J . * a D r . Frederick W . Weidm n , Philadelphia , Pa .

u . Dr . L dwig Weiss , New York City * u MO . Dr . Richard S . Weiss , St . Lo is , * Dr . Charles James White , Boston , Mass . * u . Dr . Henry Howard Whiteho se , New York City * u u Ann . Dr . Udo J li s Wile , Arbor , Mich * Dr . Charles M . Williams , New York City . * e t . Dr . Fr d Wise , New York Ci y * . t . Dr . Carroll S Wrigh , Philadelphia , Pa * Dr . Erwin P . Zeisler , Chicago , Ill .

H ONORARY MEMBERS .

Dr . L . Brocq , Paris France . n Dr . J . Darier , Paris , Fra ce . * t . Dr . George Henry Fox , New York Ci y

o se P adasso hn u. Dr . J ph , Bresla

Dr . Francis John Shepherd , Montreal , Canada.

u . Dr . P . G . Unna, Hamb rg

ASSOCIATE MEMBERS .

n . n . Dr . Joh T Bowe , Boston, Mass

n st s. Dr . Ab er Po , Cambridge , Mas M EMBERS OF T HE CONGRESS X X IX

CORRESPONDING MEMBERS .

B r r lli e a e . Ambrogio t , Milan

u u . Br no Bloch, Z rich lum bini n Co . Pio , Mode a , Italy z Kei o Dohi , Tokio , Japan .

Edward Ehlers , Copenhagen . u Ernest Finger , Vienna , A stria .

A . M . H . Gray, London, England . f’f Eric Ho mann, Bonn, Germany .

n . E . Graham Little , London, Engla d Mac L . e o d an . J . M . H , London , Engl d

. u u . L . M Pa trier , Strasbo rg, France u i P hili so n L ig p p , Palermo , Sicily . h Carl Rasch, Copen agen .

u . G . Riehl , Vienna , A stria

u u . R . Sabo ra d , Paris , France Alk m an -utc z a u u o t . L dwig Torok, B dapest , y 7

u . Norman Walker, Edinb rgh , Scotland

AMERICAN LARYNGOLO GICAL AS S OCIATI O N .

nz e un 1 8 8 r a e . O g i d J , 7

IV ACT E FELLOWS .

u t Arro wsrni th H ber , Brooklyn, N . Y .

. t James A Babbit , Philadelphia, Pa . n s t . Harry Aldrich Bar e , Bos on, Mass i John F . Barnh ll , Indianapolis , Ind .

Joseph C . Beck, Chicago, Ill .

Gordon Berry, Worcester , Mass .

. t . Herbert S Birket , Montreal , Canada M . . u O . Vilray P Blair, St Lo is , n n Joseph H . Brya , Washingto , D . C .

ut . Ralph B ler , Philadelphia, Pa anfie ld Ann . C . R Bishop , Arbor , Mich

. o o . Thomas E Carmody , Denver , C l n William B . Chamberli , Cleveland , Ohio . n J . Payso Clark, Boston, Mass .

u . Corneli s G Coakley, New York City .

George M . Coates , Philadelphia , Pa . f Lewis A . Co fin, New York City . fii n w . Co t s . Rock ell C , Bos on , Ma s

t . Algernon Coolidge, Bos on, Mass i r iniu V s . g Dabney , Washington, D C . n o Lee Wallace Dea , Iowa City , I wa.

D . Bryson Delavan , New York City . X X X IVIEMB ERS OF THE CONGRESS

e nns o o Frank Lowndes D i , Colorado Springs , C l . n . n t Francis P Emerso , Bos o , Mass .

E . ul t Ross Fa kner , New York Ci y .

t . Ralph Albert Fen on, Portland, Ore e tt f Georg Fe erol , Philadelphia, Pa .

s t . Henry Hall Forbe , New York Ci y n Thomas R . French, Brookly , N . Y . ro th in h am Richard F g , New York City . n . t O t . Perry G Goldsmith, Toron o, , Canada . M o St . u O Max A G ldstein, Lo is , .

. t Joseph L Goodale, Bos on, Mass .

Charles P . Grayson, Philadelphia, Pa. n . r t D Crosby Greene , J ., Bos o , Mass .

Joseph B . Greene, Asheville , N . C . u Thomas H . Halsted , Syrac se, N . Y .

Thomas J . Harris , New York City . n Hill Hastings , Los A geles , Cal .

t u . Lee Maidmen H rd, New York City I l r u aue . Sam el g , Cincinnati , Ohio

. t . Charles J Impera ori , New York City

n . Joh M . Ingersoll , Miami , Florida

Chevalier Jackson, Philadelphia, Pa.

E . lmer L . Kenyon , Chicago, Ill

n ux n n r . Joh Devere Ker a , J . , New York City

t . Secord Herber Larg e , Cleveland, Ohio

t o o . Rober Levy , Denver, C l

Fielding Otis Lewis , Philadelphia, Pa . n Harold I . Lillie , Rochester, Min .

z o o . Loren o B . Lockard , Denver, C l

Robert Clyde Lynch , New Orleans , La . M i ac k n N t . . e t e w John E y , York C y

u . D ncan Macpherson, New York City

E t . mil Mayer , New York Ci y

u Mc Culla h t . Sam el g , New York Ci y

E Mc Ginni s . dwin , Chicag o, Ill M Ki m i . . c m e t . . Oscar A M , Washing on, D C

Harris P . Mosher , Boston, Mass .

u . William Valentine M llin, Cleveland , Ohio n u u . Carl E . M nger , Waterb ry, Con

Robert C . Myles , New York City .

Gordon B . New , Rochester, Minn . n Horace Newhart , Min eapolis , Minn .

Francis R . Packard , Philadelphia , Pa .

Norval H . Pierce , Chicago , Ill .

u t z . u . Arth r Wal er Proet , St Lo is , Mo

B . Alexander Randall , Philadelphia , Pa . Bqalo W . Scott Renner , , N . Y .

n . . Clare ce C Rice , New York City

xxxi i M EM BERS OF THE CONGRESS

R EME ITUS FELLOWS .

. t J Price Brown, Toron o, Canada . u Frederick C . Cobb, Glo cester , Mass .

John W . Farlow, Boston, Mass .

Otto T . Freer , Chicago, Ill . i T . Melv lle Hardie , Chicago, Ill . uff F . Whitehill Hinkle , B alo, N . Y .

Frederick E . Hopkins , Springfield, Mass . u Thomas H bbard , Toledo, Ohio .

William Lincoln, Cleveland, Ohio .

R CO RESPONDING FELLOWS .

Dr . Mayo Collier , Kent, England . D e rnin u . e sv e . Dr . Carlos M , Havana , C ba tal Dr . Gherardo Ferreri , Rome , I y . n n u t . Sir James D ndas Gran , Lo don, Engla d

Dr . Adam Brown Kelly , Glasgow, Scotland . * . . t . Dr Frederick M Law, New York Ci y

Dr . Fernand Lemaitre , Paris , France . L rm e o e . Dr . Marcel y , Paris , France M Bri c d e . Dr . P . , Harrogate , England M l ac Do nad . Dr . Greville , Haslemere , England M In ac t re . Dr . John y , Glasgow , Scotland

nz . Dr . Dan Macke ie , London , England

Mc Ke rno n . Dr . James F . , New York City

Dr . Holger Mygind , Copenhagen, Denmark . ff Dr . Donald R . Paterson, Cardi , Wales .

r . . Dr . John Rogers , J , New York City

E M u . De . Dr . C . . Saj o s , Philadelphia , Pa

ff . Dr . J . Parsons Schae er , Philadelphia, Pa

n S c h m i e e lo w . Dr . Er st g , Copenhagen , Denmark

Dr . Herbert Tilley , London , England .

u u . Dr . Logan T rner , Edinb rgh , Scotland

t . Dr . Wyat Wingrave , Dorset , England

O AMERICAN SURGICAL AS S CIATI ON .

n z e une 1 860 r a . O g i d J ,

ACTIVE FELLOW 5 2

Dr . Emory G . Alexander , Philadelphia , Pa . * Dr . Edward W . Archibald , Montreal , Canada . * . . u D r Astley P . C Ashh rst , Philadelphia, Pa . M . . u O . Dr Fred Warren Bailey , St Lo is , * Dr . Franklin G . Balch , Boston, Mass . * n u f . u t Dr Do ald Ch rch Bal o r , Roches er , Minn . MEMBERS OF TH E CONGRESS xxxii i

t . Max Ballin, Detroi , Mich

ft . Frederic W . Bancro , New York City

f z n nt . Al red T . Ba i , Mo real , Canada

Edwin Beer , New York City . u Frederic A . Besley , Wa kegan, Ill . 111 u . Arth r D . Bevan, Chicago ,

u . . Arth r E Billings , Philadelphia , Pa M u O . Vilray Papin Blair , St . Lo is ,

Joseph C . Bloodgood , Baltimore , Md .

n . . Fra k K Boland, Atlanta, Ga

Richard W . Bolling, New York City .

George W . W . Brewster , Boston , Mass .

nn. Barney Brooks , Nashville , Te

f . Al red Brown, Omaha, Neb u Herbert Alexander Br ce , Toronto , Canada .

u u . John J . B chanan, Pittsb rgh, Pa

u Ann . H gh Cabot , Arbor, Mich

Alexis Carrel , New York City .

t . David Cheever, Bos on, Mass

un . . Edm d D Clark, Indianapolis , Ind ff u . . Marshall Clinton , B alo, N Y M u O . Malvern B . Clopton, St . Lo is ,

n . . A n Frederick A Coller , Arbor , Mich

John F . Connors , New York City .

Frederic J . Cotton, Boston , Mass .

n . an . Joh F Cowan, S Francisco , Cal u Harvey C shing, Boston , Mass . u Elliot C . C tler , Cleveland, Ohio .

Walter E . Dandy , Baltimore , Md . Darrac h William , New York City .

Vernon C . David , Chicago , Ill .

Carl Braden Davis , Chicago , Ill . ai St e . John g Davis , Baltimore , Md

Lincoln Davis , Boston , Mass .

n . Joh B Deaver, Philadelphia , Pa . n D la ur e to . . Henry Beeckma , Brooklyn , N Y u John Do glas , New York City .

Earle Drennen, Birmingham, Ala.

E n . t . dmo d M Eber s , Montreal , Canada E n Eldridge liaso , Philadelphia , Pa . r Ellsworth Eliot , J . , New York City .

t u . . Ar h r Wells Elting , Albany , N Y

Seward Erdman, New York City .

. t r . . William L Es es , J , Bethlehem , Pa

r . William A . Fisher , J . , Baltimore , Md

z . Charles H . Fra ier , Philadelphia , Pa

e . William Edward Galli , Toronto , Canada

u u . Otto Carl Ga b , Pittsb rgh , Pa xxxiv MEMBERS OF T HE CONGRESS

n n Joh H . Gibbo , Philadelphia, Pa .

n . Emil Goetsch , Brookly , N Y .

E . u MO . varts A Graham, St . Lo is , u Robert B . Greeno gh, Boston, Mass . L Grand u e u . . G erry , Col mbia, S C u Donald G thrie , Sayre, Pa . nn William D . Haggard , Nashville , Te . n . n Carl A Haman , Clevela d, Ohio .

M . L . Harris , Chicago, Ill .

. t . John A Har well , New York City u n Sam el C . Harvey, New Haven, Con . He d blo m Carl A . , Chicago, Ill . u George J . He er , Cincinnati , Ohio . Hi z r t o t . James Morley , New York City

e . Edward B . Hodg , Philadelphia , Pa

John Homans , Boston, Mass . n . s J Shelto Hor ley, Richmond, Va .

u . u Josh a C H bbard , Boston, Mass . Le Mo ne u n Frank y H pp , Wheeli g, W . Va . z n an MO Jabe N . Jackso , K sas City , .

ni n n . Da el Fiske Jo es , Bosto , Mass

n n . . o so Joh H J p , Philadelphia, Pa

u t . Edward Starr J dd, Roches er , Minn

n . Alle B . Kanavel , Chicag o, Ill

t . . William L . Keller , Washing on , D C

. t . . Harry H Kerr , Washing on, D C

n . Frank H . Lahey, Bosto , Mass

u n. Arth r A . Law, Minneapolis , Min

u . . B rton J Lee , New York City

t . Walter Es ell Lee, Philadelphia , Pa

Dean Lewis , Baltimore , Md . E William . Lower , Cleveland , Ohio .

t . Henry H . M . Lyle , New York Ci y

M i ff . . c Gu re u . Edgar R , B alo , N Y

u Mc Gui re . St art , Richmond , Va

u Mc Ke nna . H gh , Chicago , Ill

n . Urba Maes , New Orleans , La

Frank S . Mathews , New York City . nn Charles H . Mayo , Rochester , Mi .

William J . Mayo , Rochester , Minn .

t . Richard H . Miller , Bos on, Mass

r . Robert Talbot Miller , J . , Baltimore , Md

Charles F . Mitchell , Philadelphia , Pa .

n t . . James F . Mitchell , Washi g on, D C

. t . Charles G Mix er , Boston , Mass

t t . William Jason Mix er , Bos on , Mass

Edward C . Moore , Los Angeles , Cal .

John J . Morton, Rochester , N . Y . M EMBERS OF THE CONGRESS X X X V

u George P . M ller , Philadelphia, Pa . ' Nafi z i e r n Howard C . g , San Fra cisco, Cal .

. n n O t . Ingersoll Olmsted , S Hamilton, , Ca ada . u D dley White Palmer, Cincinnati , Ohio . n Nelso M . Percy, Chicago , Ill . f ff Damon B . P ei er, Philadelphia , Pa.

Dallas B . Phemister , Chicago, Ill . u u Sam el C . Pl mmer, Chicago , Ill . u E gene H . Poole, New York City .

Charles A . Porter, Boston, Mass .

Alexander Primrose , Toronto , Canada . n . n Fred W Ranki , Rochester , Min .

Mont Rogers Reid , Cincinnati , Ohio .

Edward P . Richardson, Boston, Mass .

. u nn Harry P . Ritchie , St Pa l , Mi . t n John Stewar Rodma , Philadelphia, Pa .

u . t . . H bert A Roys er , Raleigh , N C

St. . Fordyce Barker John , New York City

u . M . G . Seelig , St . Lo is , Mo u n z . . Arnold Schwy er, St Pa l , Mi n

Walter A . Sherwood, Brooklyn , N . Y .

u . Arth r M . Shipley , Baltimore , Md

Channing C . Simmons , Boston, Mass .

. . t u . W E Sis r nk, Rochester , Minn

Rea Smith , Los Angeles , Cal .

Kellogg Speed, Chicago, Ill .

John Speese , Philadelphia, Pa .

. t . Clarence L S arr, Toronto, Canada

Frederic N . G . Starr , Toronto, Canada .

George David Stewart , New York City .

Harvey Brinton Stone, Baltimore , Md .

f . . Al red S Taylor , New York City

Wallace I . Terry, San Francisco, Cal .

u . . Martin B el Tinker , Ithaca , N Y

z . Fran Torek, New York City

u u . H gh H . Tro t , Roanoke , Va

. u . Philemon E Tr esdale , Fall River , Mass

Van u r . . Frederick T . Be ren , J , New York City

Edgar Albert Vander Veer, Albany , N . Y .

u . John W . Va ghan, Detroit , Mich nn William F . Verdi , New Haven , Co .

~ Be th Vinc e nt . , Boston, Mass

. t t . Jonathan M Wainwrigh , Scran on , Pa

u . Stephen H rt Watts , Charlottesville , Va

n 0 . . Alle Whipple , New York City

Wyman Whittemore, Boston , Mass .

f . Al red C . Wood , Philadelphia , Pa

n . u . Joh L Yates , Milwa kee , Wis xxxvi MEM BERS OF T HE CONGRESS

SENIOR FELLOWS

Dr . George E . M . Armstrong, Montreal , Canada .

David Barrow, Lexington, Ky . i San John Fairbairn Binn e, Diego , Cal . Ba st n t . John p Blake, Bos o , Mass

Joseph A . Blake, New York City .

George E . Brewer , New York City . t m William Barret Brins ade , Brooklyn , N . Y . k u Fran E . B nts , Cleveland , Ohio . arm al . C t . William H , New Haven, Conn

. . u s . N B Carson, St . Lo i , Mo n n t . Er es A Codma , Boston, Mass .

William B . Coley, New York City .

George W . Crile, Cleveland , Ohio . u H . W . C shing, Boston, Mass .

. t . J Chalmers Da Cos a, Philadelphia , Pa

Harry C . Deaver , Philadelphia , Pa.

F . S . Dennis , New York City .

Charles N . Dowd , New York City .

William A . Downes , New York City .

Ind . . E t Joseph R as man, Indianapolis ,

. t s . William L Es e , Bethlehem, Pa

un n n. D ca Eve, Nashville , Ten

n nn . . e Joh M T . Fi y, Baltimore , Md

n . Leonard Freema , Denver , Colo

Homer Gag e , Worcester , Mass .

u . George W . Gay , Chestn t Hill , Mass

n . Charles L . Gibso , New York City

n n . . u Thomas W H tingto , San Francisco, Cal

u . James P . H tchinson, Media , Pa

u . James A . H tchison , Montreal , Canada

t . . Rober W Johnson, Baltimore , Md

u u t . . A g s F Jonas , Omaha , Neb n z . e . Frederic Kammer r, Ct Berne , Swit erla d

t . Howard Lilienthal , New York Ci y

un . Fred B . L d, Boston , Mass

M A h r . . c rt u Lewis L , Chicag o, Ill

B . . u Mac Lare n . . M rray , St John , N , Canada

E n . dward Marti , Media , Pa

n t n . Walto Mar i , New York City

t n . William M . Mas i , Mobile , Ala

u . R dolph Matas , New Orleans , La

. Willy Meyer , New York City

. George H . Monks , Boston , Mass

. tz t . Alexis V Moschcowi , New York Ci y M u St. u O . Harvey G . M dd , Lo is , MEM BERS OF THE CONGRESS xxxvfi

u Fred T . M rphy, Detroit, Mich . u Francis W . M rray , New York City .

Thomas R . Neilson, Philadelphia, Pa .

John C . Oliver, Cincinnati , Ohio . uff John Parmenter , B alo , N . Y . k Lewis S . Pilcher, Broo lyn, N . Y . u Miles F ller Porter, Fort Wayne , Ind . f Emmet Rix ord , San Francisco , Cal .

. o Charles J Rowan, Iowa City , I wa. u John D . R shmore , Brooklyn, N . Y u Charles L . Sc dder , Boston, Mass .

Francis J . Shepherd , Montreal , Canada . nl Sta ey Stillman , San Francisco , Cal . u John Edward S mmers , Omaha , Neb .

William J . Taylor , Philadelphia , Pa .

A . Vander Veer , Albany, N . Y . u u t George T lly Va ghan, Washing on , D . C .

John B . Walker , New York City .

Francis S . Watson, Boston, Mass .

Randolph Winslow, Baltimore , Md . u H gh Williams , Boston , Mass .

George Woolsey, New York City .

H RAR ONO Y FELLOWS . f n Sir Charles Al red Ballance , London, Engla d . f Rafi'a l . e e ti Pro Bas anelli , Rome, Italy . n n Sir A thony A . Bowlby, Londo , England . h . C utro u Dr Pedro , B enos Aires , Argentine . De Mar l i . te Dr Thierry , Par s , France . f n Ei l . se sbe r n u Pro A ton g , Vien a , A stria .

. t D r Henri Har mann, Paris , France .

. . . e Dr W W K en , Philadelphia, Pa . f Sir Al red Keogh, East Grinstead , England .

. t u n Dr Rene Leriche , S rasbo rg, Fra ce . ‘ L . u o rth i o i r u u D r J les , Br ssels , Belgi m .

Sir George Makins , London, England . i Sir Berkeley Moyn han , Leeds , England . u Sir Thomas Myles , D blin , Ireland . ’ D Arc Sir y Power , London , England .

. . u Sir A W Mayo Robson, Seale , S rrey , England . u n Sir Harold Stiles , Edinb rgh , Scotla d . u Sir William Taylor , D blin, Ireland . T fli r . u e Dr Theodore , Paris , France . u t Sir C thber Wallace , London, England .

. n Dr Charles Walther , Paris , Fra ce . xxx vi ii M EMBERS OF THE CO NGRESS

AMERICAN CLIMATOLO GICAL AND CLINICAL O O AS S CIATI N .

Or anz e e em be r 1 88 g i d S p t , 3 .

V ACTI E MEMBERS . * r Roy . Adams , t D D . Washing on, D C . * r . ames ur s m ers n D J B n A b o , Loomis , N . Y . * r . alter . Bae tj e r D W A , Baltimore, Md . * r . arry ee arnes u D H L B , . . Wall m Lake, R I * r . . . . eardsley, P a D E J G B Philadelphia, . * r . arry . ray D H A B , . . Ray Brook, N Y

r . harles . ro i D C C B wn ng , . Los Angeles , Cal

. . u A . r arl r s . D E B n , Manila, P I * . n n r oh oddic yers , . D J R k B Westmo t, Ont , Canada. * r . A . . . Caul fie ld nt na D H W , Toro o, Ca da . * L Fa . u a e tte Dr R ssell y Cecil , New York City . * . . We stfie ld Dr Henry D Chadwick, , Mass .

. Dr Raymond Clarke, Brooklyn, N . Y . * . . t n Dr Thomas A Claytor, Washing o , D . C . * . n Kan Dr Logan Clenden ing, Kansas City , . * . Dr Charles Hartwell Cocke, Asheville , N . C .

Dr . Robert A . Cook, New York City . * Dr . Frank A . Craig, Philadelphia, Pa.

. . u s Dr Bayard T Crane , R tland, Ma s . * r . harles . ra sha . . D C W C nk w, Newark, N J

r . illiam dgar ar all . . D W E D n , Atlantic City , N J * n . Dr . Fra cis J Dever , Bethlehem , Pa . * Do c h z . . e Dr Alphonse R , New York City . * Dr . George Draper , New York City . * u n n Dr . Kennon D nham, Ci ci nati , Ohio . * A. u Dr . Frank Evans , Pittsb rgh , Pa . tt z Dr . John William Flinn, Presco , Ari .

Dr . Cleaveland Floyd , Boston, Mass . * nn. Dr . Bryce W . Fontaine, Memphis , Te * . u o o Dr Alexi s M . Forster , Colorado Springs , C l . * z . Dr . Thompson Fra er , Asheville , N C . * . u t . . Dr Frank Taylor F l on , Providence , R I ff f u . . Dr . Al red H . Garvin , B alo , N Y * G e lin t . . . e Dr H Rawle y , New York Ci y u Dr . James Heyward Gibbes Col mbia , S . C .

. u t o o . Dr George B r on Gilbert, Colorado Springs , C l

Dr . Alvah H . Gordon , Montreal , Canada . * Dr . L . Whittington Gorham , Albany , N . Y . * n . . Grififi Dr Walter Alden , Sharon , Mass * u . . Dr . R ssell L Haden, Kansas City , Kans

o o . Dr . J . N . Hall , Denver , C l * u t . Dr . Lo is Hamman, Bal imore , Md x1 MEMBERS OF THE CONGRESS

* r . D George W Norris , Philadelphia, Pa . * r . d ard ac ard , . D E w N P k Saranac Lake , N Y . * r . P arfitt u harles , . n D C D Gravenh rst , Ont , Ca ada . * . u r . D James E Pa llin, Atlanta, Ga *

r . er i s . D Jay P k n , Providence, R I * Dr George Morris Piersol , Philadelphia, Pa . * ' u P inc o fi s t Dr Ma rice Charles , Bal imore , Md . * . t r . D George D Por er , Toronto , Ont , Canada . * Dr William Branch Porter , Richmond, Va . * . t D r Joseph H Pra t , Boston, Mass .

. oods rice , . . J W P Saranac Lake , N Y u St art Pritchard , Battle Creek, Mich .

0 . u u Charles Probst , Col mb s , Ohio . n Rac ke m ann Fra cis Minot , Boston, Mass .

. un Walter L Rathb , Cassadaga, N . Y . u Pa l H . Ringer , Asheville , N . C .

t . Stewar R Roberts , Atlanta, Ga .

William Henry Robey , Boston, Mass . Rufii n t Sterling , Washing on, D . C . B fi' l . u u ao Nelson G R ssell , , N . Y .

John P . Sawyer , Cleveland , Ohio . S c hle ite r u Howard G . , Pittsb rgh , Pa .

u . George Cheever Shatt ck, Boston, Mass h url . . S . B R y , Detroit , Mich

F . Janney Smith , Detroit , Mich .

James H . Smith , Richmond , Va .

. t . William H Smith , Bos on, Mass

. t u . R R . Snowden, Pit sb rgh , Pa

n. Willard B . Soper , New Haven , Con

. u t . Thomas P Spr n , Baltimore , Md f Walter R . Steiner , Hart ord , Conn .

t n . . . Mar i L Stevens , Asheville , N C i t . David A . Stewart , Ninet e, Man toba

u s. Arth r K . Stone , Framingham Centre , Mas

Willard J . Stone , Pasadena , Cal .

u . William D . Stro d , Philadelphia , Pa

hn . . Jo M . Swan, Rochester , N Y

u u . J . G rney Taylor , Milwa kee , Wis n . t . . John D Thomas , Washing o , D C

n . . . u u Fra cis B Tr dea , Saranac Lake , N Y

T re o lar We arn . Joseph , Boston, Mass

o o . Gerald B . Webb , Colorado Springs , C l

u . Pa l D . White , Boston, Mass

t t . . William Charles Whi e , Washing on, D C

n . Gordo Wilson, Baltimore , Md

t . . Rober Wilson , Charleston , S C

Wo lf r h . . e t Charles C , Philadelphia, Pa

t . t . Na haniel K Wood , Bos on, Mass MEMBERS OF T HE CONGRESS xli

H ONORARY MEMBERS .

. u u Dr R pert Bl e , Washington, D . C .

Dr . Livingston Farrand , Ithaca, N . Y .

. . o rte s ue Dr R F q Fox, London, England . Gau ain v n . Sir Henry , Alton, Hampshire , Engla d

u . Dr . Edm nd L Gros , Paris , France .

f . . t . . Pro Charles F Marvin, Washing on, D C M Bri . c d e . Dr James H . , Pasadena , Cal u Sir Robert W . Philip , Edinb rgh, Scotland . f u Pro . Edo ard Rist , Paris , France . z Dr . A . Rollier , Leysin, Swit erland . ar Stu t . Sir Robert F . p , Toronto , Canada

u u . Dr . Septim s S nderland , London, England

Dr . J . Hilgard Tyndale, Lincoln, Neb . f . . c u . Pro R De o rcy Ward , Cambridge , Mass

Dr . Leonard L . B . Williams , London, England . L inl . s . Dr . y R Williams , New York City f u n i . Pro . James Corneli s Wilso , Ph ladelphia , Pa

Alm ro th . Sir Wright , London, England

CORRES PONDING MEMBERS .

Dr . Ford A . Carpenter , Los Angeles , Cal . f . . . S O . . Dr G G Eyre , Cape Town, A rica f f . f un . Dr . Wil red Gren ell , St Anthony , New o dland f Pro . Yandell Henderson, New Haven, Conn . - u . . n Lie t Col W . Glen Liston, Bombay, I dia .

n . Sir Leonard Rogers , Lo don, England

Dr . F . P . Weber , London, England . n Dr . Neville Wood , London, Engla d .

LIFE MEMBERS . a f nn. Ch rles D . Alton, Hart ord, Co

James M . Anders , Philadelphia, Pa . n . s. Horace D Arnold , Bosto , Mas

Robert H . Babcock, Chicago, Ill .

Walter C . Bailey , Boston , Mass .

Edward R . Baldwin , Saranac Lake , N . Y .

W . Jarvis Barlow, Los Angeles , Cal . B r l o . e to d o . William H g , Denver, C l Blac ka r . d e . Alexander D , Montreal , Canada n . o o . S G . Bo ney , Denver , C l

V . Y . Bowditch , Boston , Mass .

John W . Brannan , New York City . Lawraso n n Brow , Saranac Lake , N . Y . xl ii M EM BERS OF T HE CONGRESS

San n Philip King Brown, Fra cisco , Cal .

. o o William A Campbell , Colorado Springs , C l . Lo s J . O . Cobb, Angeles , Cal . n Charles Farnham Colli s , New York City . t A . Coolidge , Bos on, Mass . u J dson Daland, Philadelphia , Pa . t n Thomas Darling o , New York City . E n . o o Carroll E dso , Denver , C l . z E n . t t O t . Jabe H lliot , Toron o , , Canada .

Willis E . Ford, Utica, N . Y . F . OX o o C Gardiner, Colorado Springs , C l . n W . M . Gibso , Utica , N . Y . n Irwin C . Ha ce , Lakewood, N . J . Gu n y Hi sdale, Hot Springs , Va . n Henry W . Hoagla d , Pasadena, Cal .

Charles Godwin Jenning s , Detroit , Mich .

n z Arnold C . Klebs , Nyo , Swit erland . t n Philip Marvel , A la tic City, N . J .

Charles L . Minor, Asheville , N . C .

E . O . Otis , Boston, Mass .

W . R . F . Phillips , Charleston, S . C . n . . t . F M Pot e g er, Monrovia, Cal

C . C . Rice , New York City .

. n . . Charles W Richardso , Washington, D C

n . William D . Robinso , Philadelphia , Pa ' n Bufi al o . . Dela cey Rochester, , N Y o o Henry Sewall , Denver , C l . h ffl au r . S c e . William Gray , Princeton , N J o o Will Howard Swan, Colorado Springs , C l . u H . Longstreet Taylor , St . Pa l , Minn .

J . Madison Taylor, Philadelphia , Pa .

Herbert F . Williams , Brooklyn, N . Y .

n o o . t . Herber B Whit ey , Denver , C l

ASSOCIATE MEMBERS .

* . us . t . Dr Alphe F Jennings , Detroi , Mich

ASS OCIATI O N OF AMERICAN PHYSICIANS .

1 88 O rganiz e d 5 .

ACTIVE MEMBERS .

* n . . Dr . Joh J Abel , Baltimore , Md * al C . Dr . Thomas Addis , San Francisco ,

t n . . Dr . F . M . Allen, Morris ow , N J MEMBERS OF THE CONGRESS ) ( l i ll

* z Dr W . C . Alvare , Rochester, Minn . * Dr H . L . Amoss , Baltimore , Md .

. s . Dr . James M Ander , Philadelphia , Pa * u . . Dr . John F . Anderson, New Br nswick, N J f u . Dr . Bailey K . Ash ord, San J an, Porto Rico * u u Dr . John A er , St . Lo is , Mo . * u n Dr . J . H . A sti , Philadelphia , Pa . * . . . u t . Dr C R A strian, Bal imore , Md * Dr . O . T . Avery, New York City . * Ba r e t e . Dr . W . A . j , Baltimore , Md * Dr . F . G . Banting, Toronto, Canada . * Dr . L . F . Barker, B altimore , Md . * M . u O . Dr . David P Barr, St . Lo is , * s Dr . Charles C . Ba s , New Orleans , La . * n Dr . F . G . Blake , New Haven , Con . * b Dr . M . A . Blanken orn, Cleveland , Ohio . * . an . . . S Dr A L Bloomfield, Francisco , Cal * u n . Dr . George Bl mer , New Have , Conn * . s . Dr . Thomas R Bogg , Baltimore, Md

5 . . Dr . Charles Bond , Richmond, Ind * Dr . W . Boothby, Rochester , Minn . * Dr . Harlow Brooks , New York City . * La ra n n . . w so . Dr Brow , Saranac Lake , N Y * n Dr . Thomas R . Brow , Baltimore , Md . * Dr W . H . Brown, New York City . * . n . u s . Dr C H B ting, Madi on, Wis

. . n Dr Walter B Canno , Boston, Mass . * . . 111. Dr Joseph A Capps , Chicago , * Dr . E . P . Carter, Baltimore, Md . * Dr . R . Cecil , New York City . * Dr . A . M . Chesney , Baltimore , Md . * . . n s . Dr Henry A Christian, Bosto , Ma s l Dr . Stan ey Cobb , Boston , Mass . * f Dr . Al red E . Cohn, New York City . f . u u Dr R s Cole, New York City .

Dr . Warren Coleman, New York City . * Dr . Lewis A . Conner , New York City . * . Dr . G . F Dick, Chicago , Ill .

. . . an . Dr E C Dickson , S Francisco , Cal * Do . . h e z c t . Dr Alphonse R , New York Ci y * Dr . G . Draper , New York City .

. . . Dr C K Drinker , Boston , Mass . * B i . . . Du O s Dr E F , New York City . * . u . u Dr Arth r D D nn , Omaha , Neb .

. . u Dr C W . Edm nds , Ann Arbor , Mich . * . . . t Dr A R Elliot , Chicago, Ill . * . . . t Dr C A Ellio t , Chicago , Ill .

r . . n Ind D Charles P Emerson , India apolis , . M EMBERS OF THE CONGRESS

* Dr . Haven Emerson , New York City . n M St. u O Joseph Erla ger, Lo is, .

J . A . E . Eyster, Madison, Wis . z a R . Fit , Boston, M ss .

Simon Flexner, New York City .

W . W . Ford , Baltimore, Md .

Nellis B . Foster , New York City . u u Frie d e nwald t . J li s , Bal imore, Md

Channing Frothingham, Boston, Mass . u F . T . F lton , Providence , R . I . u E . H . F nk, Philadelphia , Pa . u Thomas B . F tcher , Baltimore , Md .

Frederick P . Gay , New York City . Ge e lin t . Henry Rawle y , New York Ci y iffin . . G t . H Z , Roches er , Minn n an A . H . Gordo , Montreal , C ada.

D . Graham , Toronto, Canada .

. . s u . M L Grave , Ho ston, Texas

. . z ffi t . J P Cro er Gri h , Philadelphia, Pa n . . ut . C G G hrie, Cincin ati , Ohio n N . B . Gwy , Toronto, Canada .

u . W . W . Hamb rger , Chicag o , Ill t W . F . Hamilton , Mon real , Canada . u Lo is V . Hamman, Baltimore , Md .

Hobart A . Hare , Philadelphia , Pa .

. . t . T S Har , New York City u J . D . Heard , Pittsb rgh, Pa .

L . J . Henderson, Cambridge , Mass .

t . W . W . Herrick, New York Ci y

t . A . F . Hess , New York Ci y

Campbell P . Howard , Montreal , Canada .

u t . J . Ramsey H nt, New York Ci y

e u . R id H nt , Boston , Mass

Ernest E . Irons , Chicago, Ill .

t . Henry Jackson, Bos on , Mass lin . o b t . James W J g , New York Ci y

Noble W . Jones , Portland , Ore .

E . P . Joslin, Boston , Mass . n Howard T . Karsner , Clevela d , Ohio .

n. n . Norma M Keith , Rochester , Min

Edward C . Kendall , Rochester , Minn .

W . J . Kerr , San Francisco , Cal .

E . S . Kilgore , San Francisco , Cal . u R . A . Kinsella , St . Lo is , Mo .

z . Oskar Klot , Toronto , Canada

u . A . K . Kra se , Baltimore , Md

Krum h aar . . b E B . , Philadelphia , Pa

. t t . A Lamber , New York Ci y MEM BERS OF T HE CONGRESS xlv

n . i H . R . M La d s , Philadelphia, Pa .

Roger I . Lee, Boston, Mass . u Sam el A . Levine, Boston, Mass .

R . L . Levy , New York City .

P . A . Lewis , Princeton , N . J . n . t . E Libma , New York Ci y Li h fi l . tc e d u L , Pittsb rgh, Pa .

Edwin A . Locke, Boston, Mass . u Leo Loeb , St . Lo is , Mo . Warfie l L n o e d . o c T g p , Baltimore, Md . o Frederick T . L rd, Boston, Mass . Mc ann . C . . William S , Rochester , N Y M . . c Co . t . G W y , Washing on, D C Mc ra C e . Thomas , Philadelphia, Pa Mc Le an F . C . , Chicago , Ill . ML r c e ste . J . S . , Birmingham, Ala u A . B . Macall m, London, Canada . Il Mac Ca um . W . G . , Baltimore , Md

u . W . W . G . Maclachlan, Pittsb rgh , Pa

n . J . J . R . Macleod, Toronto , Ca ada

Mac Ni r . . . d e W . de B , Chapel Hill , N C

r . D . Ma ine, New York City M u O . W . M . Marriott, St . Lo is ,

n . Edward H . Maso , Montreal , Canada

M aki ns . . e J . C , Montreal , Canada

J . H . Means , Boston, Mass .

Adolph Meyer , Baltimore , Md .

James A . Miller , New York City .

Joseph L . Miller, Chicago , Ill .

C . L . Minor, Asheville , N . C .

G . R . Minot , Boston, Mass .

Roger S . Morris , Cincinnati , Ohio .

Herman O . Mosenthal , New York City .

S . W . L . MOS , Boston, Mass

u . J . B . M rphy, New York City

. . u e Orlea s , a . J H M sser , N w n L

u Ann . L . H . Newb rgh , Arbor , Mich

W . L . Niles , New York City .

George W . Norris , Philadelphia, Pa .

. v . F G . No y , Ann Arbor , Mich ’ Har . . . O e osto , ass J P , B n M

u MO . W . H . Olmsted , St . Lo is ,

E . L . Opie , Philadelphia , Pa .

B . S . Oppenheimer , New York City .

. T . Ordway , Albany , N . Y

t . W . W . Palmer , New York Ci y n P arfi t u O t . . t Charles D , Gravenh rst ,

E . . A . Park , Baltimore , Md x lvi M EMBERS OF T HE CONGRESS

* Dr . William H . Park, New York City . * u Dr . James E . Pa llin, Atlanta, Ga . * 0 . . . Dr . H P Pepper, Philadelphia, Pa . * Dr . John P . Peters , New Haven, Conn . * Dr . George Morris Piersol , Philadelphia , Pa . * P inc o ffs Dr . M . C . , Baltimore , Md . * u Dr . H . S . Pl mmer , Rochester , Minn . * Dr . Joseph H . Pratt , Boston , Mass . * Rac ke m ann Dr . Francis M . , Boston , Mass .

Dr . A . N . Richards , Philadelphia , Pa . * Dr . David Riesman , Philadelphia, Pa . * 0 . . Dr . H Robertson , Chicag o, Ill . * n Dr . G . Ca by Robinson , New York City . * u Dr . M . J . Rosena , Boston , Mass . * . t u Dr Pey on Ro s , New York City .

D r . Leonard G . Rowntree , Rochester , Minn . u f Dr . Robert D . R dol , Toronto , Ont . * Dr . B . Sachs , New York City . * Dr . Joseph Sailer , Philadelphia , Pa .

Dr . R . W . Scott , Cleveland, Ohio . * t Dr . A . W . Sellards , Bos on , Mass . l S o llm ann Th o rad . Dr . H , Cleveland , Ohio . * f n Dr . Walter R . Steiner, Hart ord , Con . * f Dr . Al red Stengel , Philadelphia, Pa .

. t . D r . E . R Stit , Washington , D C .

Dr . R . P . Strong, Boston , Mass . u Dr . S . Stro se , Chicago , Ill . * f Dr . Homer F . Swi t , New York City . M . u St . u O . Dr . Albert E Ta ssig, Lo is , * Dr . W . S . Thayer , Baltimore , Md . * Tile sto n n Dr . Wilder , New Haven , Con . * f . Dr . D . Vander Hoo , Richmond , Va * Dr . D . D . Van Slyke , New York City . * u u u . t . . D r . A g st s B Wadswor h , Albany , N Y * Dr . I . C . Walker , Boston, Mass . * arfi l u W e d . Dr . L . M . , Milwa kee , Wis * Ann Dr . Aldred S . Warthin, Arbor , Mich . * o o Dr . Gerald B . Webb , Colorado Springs , C l . Ann Dr . Carl V . Weller , Arbor , Mich . * Dr . George H . Whipple , Rochester , N . Y * a . t s . Dr . Fr nklin W Whi e , Boston , Ma s * D r . P . D . White , Boston, Mass . nn . . t . Dr . S M Whi e , Minneapolis , Mi * . . t . . Dr William C White , Washing on, D C * nn u . . Dr . R ssell M Wilder, Rochester, Mi

Dr . C . S . Williamson , Chicago , Ill .

Dr . Frank N . Wilson , Ann Arbor , Mich .

u . . Lo is B Wilson , Rochester , Minn x lviii M EMBERS OF T HE CONGRESS

. . u t Dr Victor C Va ghan, De roit , Mich .

. . Dr William H Welch , Baltimore , Md . f . . Pro F Widal , Paris , France .

CORRESPONDING MEMBERS .

f . . . tt E . I , . . n n Pro T R Ellio London, W C , g la d . m I . . n , . Sir Tho as Lewis London , W C , E gland .

R EME ITUS MEMBERS .

. tt Alexander C Abbo , Philadelphia, Pa .

. . R H Babcock, Chicago , Ill .

. . E R Baldwin, New York City . n Fra k Billings , Chicago, Ill . Bla . . c kad e r A D , Montreal , Canada.

. B Meade Bolton , New York City .

John W . Brannan, New York City .

. . P K Brown, San Francisco, Cal .

R . C . Cabot , Cambridge, Mass .

C . N . B . Camac , New York City . uff Charles Cary , B alo , N . Y .

S . Solis Cohen, Philadelphia , Pa .

Joseph Collins , New York City . u n William T . Co ncilma , Boston, Mass . u Elbridg e G . C tler , Boston , Mass . n Charles L . Da a, New York City .

George Dock, Pasadena, Cal .

David L . Edsall , Boston, Mass .

. . s s . A R Edwards , Wellesley Hill , Mas

t . James Ewing, New York Ci y n n F . G . Fi ley , Mo treal , Canada . n R . G . Freema , New York City .

. n . . i . H C Gord ier , Troy , N Y l n St . u . Charles R . Gree e , Pa , Minn

u t . L dvig Hek oen , Chicago, Ill

J . B . Herrick, Chicago , Ill .

W . T . Howard , Baltimore , Md .

. . t . S W Lamber , New York City L fi r e e u . H . A . , Montreal , Canada M h P ran . . c e d A , Toronto , Canada

F . B . Mallory , Boston, Mass .

C . F . Martin, Montreal , Canada .

M fii . . . o tt H C , San Francisco , Cal t John L . Morse, Bos on, Mass .

u . W . P . Northr p , New York City

R . M . Pearce, New York City .

R . B . Preble , Chicago, Ill . M EMBERS OF THE CONGRESS X l ix

Dr . Morton Prince, Boston, Mass . Rac h fo r . . . d n Dr B K , Cincin ati , Ohio .

Dr . M . W . Richardson, Boston, Mass .

. . . u t . D r F F R ssell , New York Ci y

Dr George G . Sears , Boston, Mass . * o o Dr Henry Sewall , Denver, C l . u Dr Frederick C . Shatt ck, Boston , Mass . * . n Dr M Alle Starr , New York City . ff . . t u . C G Stock on, B alo , N Y . P alO A . E . Taylor , Alto, Cal .

H . F . Vickery, Brookline , Mass .

. tt . Henry P Walco , Cambridge , Mass

G . H . Weaver, Chicago, Ill .

H . G . Wells , Chicago , Ill . * Dr . F . H . Williams , Boston, Mass . uff H . U . Williams , B alo, N . Y .

James C . Wilson, Philadelphia , Pa .

F . C . Wood, New York City .

O O O - O AMERICAN AS S CIATI N OF GENIT URINARY SURGE NS .

r anz e c to b e r 1 886 O g i d O , .

VE MED/IB ER ACTI S .

Nathaniel G . Alcock, Iowa City , Iowa . n J . Dellinger Barney, Bosto , Mass . B n enj amin S . Barri g er, New York City .

u . Montag e L Boyd , Atlanta , Ga .

William F . Braasch , Rochester , Minn . n Robert C . B rya , Richmond, Va . r u Hen y G . B gbee, New York City .

. u u Hermon C B mp s , Rochester , Minn . M f . u . u O . C . E B r ord, St Lo is ,

t . u . Jona han E B rns , Kansas City, Mo u H gh Cabot , Ann Arbor , Mich . M u u O . John R . Ca lk, St . Lo is , LO u . S Arth r B Cecil , Angeles , Cal .

Ch e tw o d . . o Charles H , New York City

u . u . Arth r L Ch te, Boston , Mass

J . Bayard Clark, New York City .

J . A . C . Colston , Baltimore , Md .

Ernest G . Crabtree , Boston, Mass .

John L . Crenshaw , Rochester , Minn .

u . Arth r H Crosbie , Boston , Mass .

Andrew J . Crowell , Charlotte , N . C .

u . Harry C lver , Chicago , Ill

n . u . Joh H C nningham, Boston , Mass M EMBERS OF THE CONGRESS

Edwin Davis , Omaha , Neb . n Clyde Leroy Deming , New Have , Conn .

Francis C . Edgerton, New York City .

. t . . Harry A Fowler , Washing on, D C ro ntz William A . F , Baltimore, Md .

. u t . Homer G F ller , Washing on , D C .

Roger C . Graves , Boston, Mass .

. n . t . Francis R Hagner , Washing o , D C

Homer G . Hamer , Indianapolis , Ind . San Frank Hinman, Francisco, Cal . u Joseph H me , New Orleans , La .

ne . u t n Ver C H n , Rochester , Min .

Howard S . Jeck, New York City .

Edward L . Keyes , New York City .

Herman L . Kretschmer, Chicago, Ill . u u Thomas F . La rie, Syrac se , N . Y .

u . Lo is C Lehr, Washing ton , D . C .

. nn George R Livermore , Memphis , Te .

William E . Lower , Cleveland , Ohio . Mac Ke nz ie David W . , Montreal , Canada .

. c t . Joseph F Mc arthy , New York Ci y M K nna c e . Charles M . , Chicago, Ill

Henry H . Morton , Brooklyn , N . Y . ’ n O Co o r . t . Vincen J , Chicago , Ill ’

N il . . O e Richard F , Boston , Mass f Al red T . Osgood , New York City .

u . . Arth r H Paine , New York City

Frank S . Patch , Montreal , Canada .

James Pederson , New York City .

u . William C . Q inby , Boston, Mass

Alexander Randall , Philadelphia , Pa .

u . . Nathaniel P . Rathb n , Brooklyn, N Y

f . Henry L . San ord, Cleveland , Ohio

u . Lo is E . Schmidt . Chicago , Ill L OS . A . J . Scholl , Ang eles , Cal

u . Thomas P . Sh pe , Cleveland , Ohio

t . George S . Smith , Bos on , Mass

u t . J . Bentley Sq ier , New York Ci y

Alexander R . Stevens , New York City .

nn. Gilbert J . Thomas , Minneapolis , Mi

t . George W . Warren , New York Ci y

William P . Willard , San Francisco , Cal .

u . u t . H gh H Yo ng, Bal imore , Md

FELLOWS .

t . Dr . Gardner W . Allen , Bos on , Mass

t . . Dr . Rober H Greene , New York City M EMBERS OF THE CONGRESS l i

n n an n . S . Harry M Joh so , A tonio , Texas

un . Edm d E King, Toronto , Canada . f M u O . Brans ord Lewis , St . Lo is , a u u H rvey G . M dd, St . Lo is , Mo . u Emory W . R ggles , Rochester , N . Y .

E . H . Siter , Philadelphia, Pa . u Pa l Thorndike , Boston, Mass . f Al red C . Wood , Philadelphia, Pa .

HONORARY MEIMBERS

Be lfie ld William T . , Chicago, Ill .

. e . George E Br wer, New York City u u e E gene F ll r, New York City . n Charles L . Gibso , New York City .

Edward Martin, Philadelphia, Pa .

Abner Post , Cambridge , Mass .

. t u Francis S Wa son, Dartmo th , Mass .

William N . Wishard, Indianapolis , Ind .

CORRESPONDING MEMBERS .

u n n . Mr . E . H rry Fenwick, Lo don, E gland f F r . . . e d o v t u . Pro Serg Petr , Pe rograd , R ssia f anbra n . . e u Pro Emile J , Montpelier, Fra ce i Mr . Frank K dd, London, England . hn n Mr . Jo Pardoe, London, Engla d . f f u n u . Pro . Al red Po sso , Bordea x , France f n . . u u z Pro Caesar Ro x , La sanne, Swit erla d f u n n r n u . . Ve h o e e Pro Jea Re e g , Br ssels , Belgi m

Sir J . W . Thompson Walker , London, Eng land .

AMERICAN ORTHOPEDIC AS S OCIATI ON .

Ma 1 88 r anz e d . O g i y , 7

ACTIVE MEMBERS .

Le Ro . u . t . y C Abbot , St Lo is , Mo

Edville G . Abbott , Portland , Me .

n . Joh Adams , Boston , Mass

Zabdiel B . Adams , Boston , Mass .

Fred H . Albee , New York City .

Nathaniel Allison, Boston, Mass .

William S . Baer , Baltimore , Md .

u . t . Sam el C Baldwin , Salt Lake Ci y, Utah

n . George E . Be nett , Baltimore , Md M EMBERS OF TH E CONGRESS

. t R Wallace Billing on, Nashville , Tenn .

. t William E Blodg et , Detroit , Mich .

E . t lliott G Bracket , Boston, Mass .

Albert H . Brewster , Boston, Mass . r n A . Ba ey Brooks , Nashville , Tenn . n . as . Lloyd T Brow , Boston, M s

Willis C . Campbell , Memphis , Tenn .

u . Arth r H Cilley , New York City . u William Arth r Clark, Pasadena, Cal .

. Co fie ld t Robert B , Cincinna i , Ohio .

. . u n H Wallace Cole , St Pa l , Min . n n . Sid ey M Co e , Baltimore , Md . nn Harold R . Co , Akron , Ohio . nf u . t M rray S Da or h , Providence , R . I . k n . t MO Fran D Dickso , Kansas Ci y , . n unl Joh D op , Pasadena , Cal . Eik nbar . e Charles F y , Seattle , Wash .

Benj amin P . Farrell , New York City .

. u . Eben W Fiske , Pittsb rgh, Pa

Ralph R . Fitch , Rochester, N . Y .

Ma K nz i . c e e A Forbes , Montreal , Canada .

Albert H . Freiberg, Cincinnati , Ohio . F n n t . u ste . Rober V , Detroit , Mich n u Fred J . Gae slen, Milwa kee , Wis . t William E . Gallie , Toron o, Canada.

Emil S . Geist , Minneapolis , Minn .

Ralph K . Ghormley , Boston , Mass .

Alexander Gibson, Winnipeg, Canada . u A . Br ce Gill , Philadelphia , Pa .

n . Rola d Hammond , Providence , R I .

R . I . Harris , Toronto, Canada .

George W . Hawley, Bridgeport , Conn .

n . M . S . He derson, Rochester , Minn

u . . R ssell A Hibbs , New York City

Frederick G . Hodgson, Atlanta , Ga .

t . Michael Hoke , Atlan a, Ga

Charles M . Jacobs , Chicago , Ill .

Charles H . Jaeger , New York City .

t . . Rober W Johnson , Baltimore , Md

LO S . Ellis W . Jones , Angeles , Cal

u . . H gh T Jones . Rochester , Minn

o o . S . Fosdick Jones , Denver , C l

u . John A . Key , St . Lo is , Mo

Frederick C . Kidner, Detroit , Mich .

u . Sam el Kleinberg , New York City

t Le B re to n uff . . Prescot , B alo , N Y

u . . Arth r T Legg, Boston , Mass

Le M suri r . . . e e A B , Toronto, Canada M EMBERS OF THE CONGRESS ‘ 1iii

Philip Lewin, Chicago, Ill .

John Prentiss Lord , Omaha, Neb . L L e R. OS Charles Lowman, Angeles , Cal . Mac Ausland . . t . W R , Bos on, Mass u H . P . Ma ck, Richmond, Va .

t . Leo Mayer , New York Ci y uff Roland O . Meisenbach , B alo , N . Y .

William J . Merrill , Philadelphia, Pa . M r in n e e d . Henry W . y g , Rochester , Min

Oscar Lee Miller, Charlotte , N . C .

Nac hla . . s I W . , Baltimore, Md l Charles D . Napier , Brook yn, N . Y .

Philip W . Nathan, New York City . u John J . N tt , New York City .

Frank R . Ober , Boston, Mass .

Charles Ogilvy , New York City .

H . Winnett Orr , Lincoln, Neb . ’ MO O Re ill . u . James Archer y , St Lo is ,

Robert B . Osgood , Boston, Mass . u William B . Owen, Lo isville, Ky . h Dallas B . Phemister , C icago , Ill . ff u u . . W . W . Pl mmer, B alo, N Y

John L . Porter , Evanston, Ill .

H . L . Prince , Rochester , N . Y .

Ri e l . Compton y , Baltimore , Md

Percy W . Roberts , New York City .

David E . Robertson , Toronto, Canada .

Mark H . Rogers , Boston, Mass .

. u hiladelphia, a . J Torrance R gh , P P

Edwin W . Ryerson , Chicago, Ill . M M h ffl r O . c E. S c au e Robert , Kansas City,

Robert Schrock, Omaha, Neb .

James Warren Sever , Boston, Mass .

u . David Silver , Pittsb rgh , Pa

- u . Mari s N . Smith Petersen , Boston, Mass

u . Robert So tter, Boston, Mass

Kellogg Speed , Chicago, Ill . n James Spencer Speed, Memphis , Ten .

Clarence L . Starr , Toronto , Canada .

u S te ind le r . Arth r , Iowa City, Iowa

Walter G . Stern , Cleveland, Ohio . MO u . Joseph E . Stewart , St . Lo is , s Loring T . Swaim , Boston, Ma s . f u . . Pa l P Swett , Hart ord , Conn

Henry B . Thomas , Chicago, Ill .

J . E . M . Thomson , Lincoln, Neb .

n . Lawson Thornton, Atla ta, Ga u l Walter Tr slow , Brook yn , N . Y . l iv M EMBERS OF T HE CONGRESS

u n William G . T r er , Montreal , Canada .

Charlton Wallace, New York City .

. 0 . u J Wallace , Pittsb rgh, Pa .

e . i San Jam s T Watk ns , Francisco, Cal .

Brainerd Whitbeck, New York City . e t n Armitag Whi ma , New York City . F r De o e st . P Willard, Philadelphia , Pa . L n . O S Joh C Wilson, Angeles , Cal . n Philip D . Wilso , Boston, Mass .

H ONORARY MEMBERS .

u s Dr . Jacq e Calve , Berc Plage , France . u n . en . Dr M rk Ja sen, Leid , Holland

Sir Robert Jones , Liverpool , England . u n . tt t . Dr Vittorio P i , Bolog a, I aly * l Dr . John Rid on, Chicago , Ill .

EMERITUS MEMBERS . f Ansel G . Cook, Hart ord , Conn .

t . John Dane, Bos on, Mass

E tt . George R . llio , New York City

H . P . H . Galloway , Winnipeg , Canada .

E . Joel . Goldthwait , Boston, Mass M ff . u O . Philip Ho man, St Lo is , L r t e Ro Mc Cu d u . Stewar y y , Pittsb rgh , Pa

Reginald H . Sayre, New York City .

n . . t . A R . Shands , Washing o , D C

. u t . R T ns all Taylor , Baltimore , Md

William J . Taylor , Philadelphia , Pa .

Twinc h . . Sidney A . , Newark, N J

u u u e t . A g st s Thorndik , Bos on, Mass

Royal Whitman, New York City .

CORRESPONDING MEMBERS . n us Bilh aut a . Marcea , Paris , Fr ce

zz . Ricardo Galea i, Milan, Italy

Ki rm i i n . . ss o E , Paris , France

E . . u t M irhead Li tle, London, England

W . S . New, Shanghai , China . n Harry Platt , Manchester , Engla d . z n u u . Wilhelm Sch lthess , Z rich , Swit erla d f n u E . Al red H . T bby , Lo don, ngland l vi M EMBERS OF T H E CONGRESS

. t . B Raymond Hoobler , De roit , Mich

P . C . Jeans , Iowa City , Iowa .

Charles G . Kerley , New York City . r J . H . Mason Knox , J . , Baltimore , Md . K Benj amin ramer , Brooklyn, N . Y .

Maynard Ladd , Boston, Mass . LaFe tra L . E . , New York City . u William Palmer L cas , San Francisco, Cal .

. . c . H M Mc lanahan, Omaha, Neb M lur . c C e n 111 William B , Evansto , .

u c u . u M O . H gh Mc lloch , St Lo is , M arri c u e t . . Irvine Q , Roches er , N Y Mc Kim u MO Marriott , St . Lo is , .

. n A Graeme Mitchell , Cinci nati , Ohio .

John Lovett Morse , Boston , Mass . u n u u William A . M lheri , A g sta , Ga . ff M . O . Frank C Ne , Kansas City, n . Sa R Langley Porter, Francisco , Cal .

Grover F . Powers , New Haven, Conn .

. u . Walter R . Ramsey, St Pa l , Minn

Thomas Milton Rivers , New York City .

. . nn. F C Rodda, Minneapolis , Mi n S . G . Ross , Montreal , Ca ada . ni . t . Lawrence T Roys er, U versity, Va Ruh rah John , Baltimore , Md .

Bela Schick, New York City .

Oscar M . Schloss , New York City . h l z n . Sc ut . Frederic W , Minneapolis , Min

u . Lo is C Schroeder , New York City . h am n S e . Max , Minneapolis , Min

Henry L . K . Shaw, Albany, N . Y . ff w u . t . . De it H Sherman , B alo , N Y

u . . Pa l G Shipley , Baltimore , Md

u u . James B ren Sidb ry, Wilmington , N C .

n . Warre R . Sisson, Boston , Mass

a t . Ch rles Hendee Smith , New York Ci y

i . Richard M . Sm th , Boston, Mass z Frit B . Talbot, Boston , Mass . nn Rood Taylor , Minneapolis , Mi .

F . F . Tisdall , Toronto, Canada . nIn n Va e . Philip g , New York City M u O . Borden S . Veeder , St . Lo is ,

Herbert B . Wilcox , New York City .

EMERITUS MEMBERS . l . k B ac ad r . . . e Dr A D , Montreal , Canada

u u u . Dr . A g st s Caille , New York City M EMBERS OF THE CONGRESS l vii

n Joh Dorning, New York City .

Percival J . Eaton , Provincetown, Mass . n u t . Fra cis H ber , New York Ci y

D . J . Milton Miller , Atlantic City , N . J . u William P . Northr p , New York City . Rac h f r . o d n i B . K , Cincin ati , Oh o . uff Irving M . Snow, B alo , N . Y .

. u t Thomas S So thwor h , New York City . t Thompson S . Westcot , Philadelphia . Pa .

H M ONORARY ME BERS .

f f u . . uz n e . Pro G Ara Al aro , B enos Aires , Argenti n -D Lill . e e . Dr . P F . Arma d , Paris , France z Dr . Adalbert C erny , Berlin, Germany . n . n Dr Leo ard Findlay, Glasgow, Scotla d . u n Dr . V . H tinel , Paris , Fra ce . u n Sir Tr by King, New Zeala d .

f n . Dr . A . Mar a , Paris , France i u u . u u Dr L s Morq io, Montevideo, Ur g ay .

u E n . Sir Arth r Newsholme , London, ngla d n Dr . George F . Still , London, Engla d .

CORRESPONDING MEMBERS .

n . u . Dr . A g elo A Aballi , Havana, C ba n e n u . Dr . L on Velasco Bla co, B enos Aires , Arg enti e

u Th ursfie ld n . Dr . H g h , London, Engla d

THE AMERICAN AS S OCIATI ON OF PATHOLOGI ST S

AND BACTERI OLOGI STS .

r anz e 1 O g i d 899.

B MEM ERS .

u E . nt n Ma de Abbott, Mo real , Ca ada .

Herman M . Adler , Chicago, Ill . nr A He y lbert , Des Moines , Iowa.

Harold L . Amoss , Baltimore , Md . n u Joh F . Anderson , New Br nswick, N . J .

Aaron Arkin , Chicago , Ill .

u . . B rdett L Arms , Jacksonville , Fla

Lloyd Arnold, Chicago , Ill .

Joseph D . Aronson , Philadelphia , Pa .

u . J . Harold A stin , Philadelphia , Pa

. u t t . Richard S A s in, Cincinna i , Ohio lvi i i M EM BERS OF T HE CONGRESS

r . harles . ustria D C R A n, . Baltimore , Md

r . s ald T . very D O w A , New York City .

. . r ames yer . D J B A , Boston, Mass

. Dr George Baehr , New York City .

. r ercival ailey . D P B , Chicago, Ill f . . D r Al red W Balch , Piermont, N . Y .

. . uf u Dr Leon K Balda , Lo isville, Ky .

. . Dr Edward R Baldwin, Saranac Lake, N . Y .

. . be r arshall ar r . D M A B , Greenwood, Miss

. n Dr Moses Barron, Minneapolis , Min .

. . e tt nn r harles . D C J Bartl , New Haven , Co

. . nt n Dr Joseph E Bates , Toro o , Ca ada .

. . u tn f r d i a mgar er . D E w n A B , Cli ton Springs , N Y . n - . t Dr S a hope Bayne Jones , Rochester , N . Y B il . e b Dr George E . y , Albany , N . Y .

D r . David L . Belding, Boston, Mass .

. . . Dr E T Bell , Minneapolis , Minn .

t . Dr . Rober L Benson, Portland , Ore .

. . z uff Dr Charles A Bent , B alo, N . Y .

Dr . Benj amin Berg, New York City . B e rn n . to Dr . Harry S , Washington, D . C . n . . Bie rri n Dr Walter L g , Des Moi es , Iowa .

n . . nn. Dr Fra cis G Blake , New Haven, Co

Dr . William Bloom, Chicago, Ill .

Dr . Mark F . Boyd , Edenton , N . C . n D r . William Boyd, Winnipeg, Ca ada .

. nn Dr . Albert C Broders , Rochester , Mi . Bro nfe nbr nn r u M e e . O Dr . Jacob , St Lo is , . n Dr . Wade H . Brow , New York City . nn . . u n Dr Andrew A Br ere , Montreal A ex, Ca ada .

u t . Dr . Leo B erger , New York Ci y u Dr . Carroll G . B ll , Baltimore , Md .

u . Dr . H . Hays B llard , London, Ont , Canada . u Dr . Charles H . B nting , Madison, Wis .

. . u e e s Cal . Dr Montrose T B rrows , Los Ang l , e s Dr . George T . Caldwell , Dallas , T xa , f un . Dr . Henrietta A . Calho , Rock ord, Ill

Dr . George R . Callender , Washington, D . C . ' Arbo r Mic h Dr . Carl D . Camp , Ann , .

v n 1 . Dr . Myrtelle M . Cana a , Boston 7, Mass

u n . D r . Pa l R . Can on, Chicago , Ill

n . . Dr Charles M . Carpe ter , Ithaca , N Y

Dr . Aldo Castellani , New Orleans , La .

u . . Dr . R ssell L Cecil , New York City

La . . d e Dr . C . E Chapelle , New York City

nn. Dr . Albert J . Chesley Minneapolis , Mi

t . Dr . Henry A . Christian , Bos on , Mass

n . n . u Dr . Joh W Ch rchma , New York City MEMBERS OF THE CONGRESS li x

. . r e j ami . D B n n J Clawson, Minneapolis , Minn

. . d n In . Dr George H A Clowes , In ia apolis , d

. n Dr Stanley Cobb, Bosto , Mass . f . n Al red E Coh , New York City . f u u . R s I Cole , New York City .

. u Katherine R Collins , Spartanb rg, S . C .

Claribel Cone , Baltimore , Md .

Charles L . Connor , Boston, Mass .

. Co r e r n arry o o . H J p , De ver, C l n i . Co rso wh te Ellen P , Philadelphia , Pa . u . t . . James F Co pal , Washing on, D C u u n Ma rice Co ret , New Orlea s , La .

David M . Cowie , Ann Arbor , Mich . f Baxter L . Craw ord , Philadelphia, Pa.

George W . Crile , Cleveland , Ohio . u Sam el J . Crowe , Baltimore, Md .

Bowman C . Crowell , Chicago , Ill . a u n Thom s S . C lle , Baltimore , Md . u William T . C mmins , San Francisco, Cal . u Harvey C shing, Boston, Mass .

Thomas L . Dagg, Chicago . Ill .

. t . David J Davis , Wilmet e , Ill Ann James E . Davis , Arbor, Mich .

Nelson C . Davis , New York City .

George F . Dick , Chicago, Ill .

Ernest C . Dickson, San Francisco, Cal . u Charles W . D val , New Orleans , La .

. t . Edmond M von Eber s , Montreal , Canada u Enriq e E . Ecker , Cleveland , Ohio . E sto n Andrew A . g g , New York City . Ei se nbr u . e . Arth r B y , Cleveland , Ohio

Aller G . Ellis , Bangkok, Siam .

t . William J . Elser , New York Ci y

S O . . Newton Evans , Pasadena , Cal

James Ewing, New York City .

Marshall Fabyan, Boston , Mass . Fa ul n u m e e r . Lem el , New York City

n n. William H . Feldma , Rochester , Min

u . Cyr s W Field , New York City . z n J . G . Fit gerald, Toronto, Ca ada . M u O . Moyer S . Fleisher , St . Lo is ,

n t . Simo Flexner , New York Ci y

s. Cleaveland Floyd , Boston, Mas

n uff . . Alvi G . Foord , B alo, N Y

. t . N Chandler Foo , Cincinnati , Ohio

William W . Ford , Baltimore , Md .

Herbert Fox , Philadelphia , Pa .

u un . H go A . Fre d, Detroit , Mich 1x M EM BERS OF THE CONGRESS

r t r . a s . Cha ming Fro hingham, J , Boston , M s nk u t n Fra T . F l o , Providence, R . I . n un Joh F ke, Atlanta , Ga .

. t Abraham L Garba , New York City . n . a Leroy U Gard er, Saran c Lake , N . Y .

Frederick P . Gay, New York City . ut n R h Gilbert , Alba y, N . Y .

u . n . Sam el H Gillila d, Marietta, Pa tn Ward Gil er, East Lansing , Mich . f n u n Al red S . Giorda o, So th Be d , Ind . l n . Go m s e t . Da iel J , Des Moines , Iowa f J . L . Go orth, Dallas , Texas , nx u . Sam el A Goldberg , Bro , N . Y . n Joseph Goldberger, Washingto , D . C .

Harry Goldblatt , Cleveland , Ohio . nn . s u . Ernest W Goodpa t re , Nashville , Te

. o . . Frederic P G rham , Providence , R I n George S . Graham , Birmi gham, Ala .

tu t u . S ar Graves , Lo isville , Ky u Lo is Gross , New York City .

t u . . Ar h r L Grover , Reno, Nevada u Fraser B . G rd , Montreal , Canada . M u . n O . R ssell L Hade , Kansas City ,

n . . William A . Hag a , Ithaca , N Y nn an Carl A . Hama , Clevel d , Ohio .

n n . . s George H Ha ema , Iowa City , Iowa

S . u t . D . L . Harris , Lo is , Mo Ma L . c . s t . N Harri , Ot awa , Canada

William H . Harris, New Orleans , La .

n . F . W . Hartma , Detroit , Mich

Thomas W . Hastings , Kinderhook, N . Y .

u n u . Sam el R . Haythor , Pittsb rgh , Pa

u t . L dvig Hek oen , Chicago , Ill ns F . C . Helwig , Kansas City , Ka . f Al red F . Hess , New York City . n MO Cora Hesselberg, Jopli , .

n . Oliver S . Hillma , New York City

Edwin F . Hirsch , Chicago, Ill .

s . . A . Parker Hitchen , Manila , P I

n . William L . Holma , Toronto , Canada

i . Joseph G . Hopk ns , New York City n w . Campbell Ho ard , Montreal , Ca ada

Katherine M . Howell , Chicago , Ill .

u . G . Carl H ber , Ann Arbor , Mich

. uff n . Otto V H ma , New York City

u t O re . W . C . H nter , Por land ,

nk u n . Fra M . H ntoo , Glenolden, Pa nn S u . e t . K . Ik da, Pa l , Mi M EMBERS OF THE CONGRESS l xi

Ernest E . Irons , Chicago , Ill . uff William F . Jacobs , B alo, N . Y .

Leila Jackson, Chicago , Ill .

Conrad Jacobson, Seattle , Wash .

Victor C . Jacobson, Albany, N . Y . ff Henry L . Ja e , New York City . ff Richard H . Ja e , Chicago, Ill . blin . o t . James W J g , New York Ci y

William C . Johnson , New York City .

Frederic S . Jones , Princeton, N . J .

Edwin O . Jordan , Chicago , Ill .

n blut . . . u e t C W J g , New York Ci y

u . Re ben L Kahn, Lansing, Mich .

Howard T . Karsner , Cleveland , Ohio .

Ellis Kellert , Schenectady, N . Y . M u . u O . Arth r I Kendall , St . Lo is , M L i u c . . H gh K nghorn , Saranac Lake , N Y . K f Howard N . ings ord , Hanover , N . H . Kinni c ut a t . Roger , Worcester , M ss

Mary B . Kirkbride, Albany , N . Y .

u . Pa l Klemperer , New York City z Oskar Klot , Toronto , Canada .

John A . Kolmer , Cynwy d, Pa .

Anatole Kolodny , Iowa City, Iowa .

n . u . Alle K Kra se , Baltimore , Md

Krum h a . . b ar Edward T , Philadelphia, Pa

i . u r . . Charles Kr mwiede , J , Bronxv lle , N Y

t . Pres on Kyes , Chicago , Ill

u . G . R . Lacy , Pittsb rgh , Pa

. u u . Richard V Lamar , A g sta , Ga

u . R . A . Lambert, San J an , Porto Rico

f . J . A . Lan ord , New Orleans , La

W . P . Larson, Minneapolis , Minn .

T . Leary , Boston, Mass . L n . . e Co u t . E R , Chicago , Ill ’

LE ran . . s e c e E S . p , New York City

Isaac Levin , New York City .

J . H . Lewis , Chicago , Ill .

u . . . Pa l A Lewis , Princeton , N J

E . Libman , New York City .

S . u . Leo Loeb , t Lo is , Mo

n . o . Leo L ewe , Brookly , N Y

E . R . Long, Chicago , Ill .

L . G . Lowrey , Cleveland , Ohio .

u . Baldwin L cke , Philadelphia , Pa

u . M . B . L rie , Philadelphia, Pa u Harold W . Lyall , Perrysb rg, N . Y .

. . t . . K M Lynch , Charles on , S C M EM BERS OF TH E CONGRESS

uff I . P . Lyon, B alo, N . Y .

r u . M . W . Lyon , J . , So th Bend , Ind

M ar n n. . . c C t e J S y , Minneapolis , Min r k M M o d o c u O . c C . H . A . , St Lo is ,

Mc o . . . C . . t Dr G W y , Washing on, D C ni l n Mc Da e . Dr . O . , Minneapolis , Min

Mc Farland e . Dr . Joseph , G rmantown, Pa Mc Glum h i Dr . Charles B . p y , Ch cago , Ill . M In h . c to s . Dr . J . A , Memphis , Tenn M ki n n . u M . c u O . D r . F . A J , St Lo is , M K . . c e n . . e Dr S H , Montreal , Ca ada Mc Maste r Dr . P . D . , New York City . Mc Me ans u Dr . J W . , Pittsb rgh , Pa . Mc Nam ara . u u u F . P , D b q e, Iowa .

. . c u W G Mac all m , Baltimore, Md . Mac ar . . C t t nn. W C y , Roches er , Mi nz G . M . Macke ie, New York City . Mac Lac hlan . . . u W W G , Pittsb rg h, Pa . Ma N al W. c e . . I. J , Forest Hills , L . , Mac Ni r . d e W deB . , Chapel Hill , N . C . hi abe . . e t O R , Toron o, Canada . illiam n n W Mag er , Toronto, Ca ada .

R . H . Major , Rosedale , Kansas .

F . B . Mallory , Boston , Mass . n P . J . Ma heims , New York City . f . n W . H Manwaring , Stan ord U iversity, Cal .

David Marine , New York City . n f . . v. t H T Marshall , U i Pos O fice, Va . Maxim o w A . A . , Chicag o, Ill .

E . M . Medlar, Madison, Wis . a u . . . Lo ise H Meeker , Sc rsdale , N Y n u o o . H g o Mella , De ver, C l u R . R . Mellon, Pittsb rgh , Pa .

F . R . Menne , Portland, Ore . u M . L . Menten, Pittsb rgh , Pa .

f . Adol Meyer , Baltimore , Md n Karl F . Meyer , San Fra cisco , Cal .

James Miller , Kingston , Ont . , Canada . - R . o o . . G Mills , Denver, C l an L . S . Milne , K sas City, Mo .

E Mil la i h u . . . o s v c L , Milwa kee , Wis

u . O . W . H . Mitchell , Syrac se , N . Y

Harris Moak, Brooklyn, N . Y .

n . V . . . H Moo , Philadelphia, Pa

. . . e hicago , ll . J J Moor , C I

. e . V . A Moor , Ithaca , N Y

z n . A . R . Morit , Clevela d , Ohio

P . s t . . . F Mor e, De roit , Mich l xiv M EMBERS OF TH E CONGRESS

. . nn H E Robertson , Rochester, Mi .

. r . o W . H Robey, J , B ston, Mass .

. . n W L Robinson, Toronto, Ca ada . u G . L . Rohdenb rg, New York City . uff Benj amin Roman , B alo, N . Y .

. . u s M J Rosena , Boston, Mas .

. . nn. E C Rosenow, Rochester, Mi

M . A . Rothschild , New York City .

T . C . Rothstein , Chicago , Ill . t us Pey on Ro , New York City . u G . F . R ediger , Altadena, Cal . u San G . Y . R sk, Francisco , Cal . ff . . u u . N G R ssell , B alo, N Y .

Otto Saphir , Cleveland , Ohio .

M . J . Schlesinger , Boston , Mass .

H . C . Schmeisser , Memphis , Tenn . h M . . S c o re r O . E H , Kansas City, f . . u z O . . E W Sch lt , Stan ord University, P , Cal ul z O . T . Sch t , Chicago , Ill .

. . u z u . . O H Sch lt e , H ntington , N Y u u Ernest Scott , Col mb s , Ohio .

. S e c o f . e . D P , New York City

N . P . Sherwood , Lawrence , Kans .

J . S . Simmons , Washington, D . C .

J . P . Simonds , Chicago , Ill . uff B . T . Simpson , B alo , N . Y . i . S t nfi l . . te e d M J , New York City

D . T . Smith , Ray Brook, N . Y . u G . M . Smith, Waterb ry , Conn .

H . P . Smith , Rochester , N . Y .

L . W . Smith , Boston, Mass . n n e t . . Theobald Smith , Pri c o , N J

H . C . Solomon , Boston , Mass .

E . F . . Sondern, New York City

. . u . M H So le , Ann Arbor , Mich

u . T . P . Spr nt , Baltimore , Md

A . V . St . George , New York City .

E . M . Stanton , Schenectady , N . Y .

A . E . Steele , Roslindale , Mass .

. t . B S einberg, Toledo , Ohio f . t . Walter R S einer , Hart ord , Conn

A . Stengel , Philadelphia , Pa .

. . n . . H N Stevenso , Pelham , N Y

. . t . F W Stewar , New York City

R . G . Stillman , New York City .

R . P . Strong, Boston , Mass . u Do glas Symmers , New York City .

R . M . Taylor , Paris , France . M EMBERS OF TH E CONGRESS l xv

T e n . C . Broeck, Peking, China n B . T . Terry, Nashville , Te n.

Th alh im e r u . William , Milwa kee , Wis

H . S . Thatcher , Little Rock, Ark . f n . W . S . Thomas , Cli to Springs , N M u O . R . L . Thompson, St . Lo is ,

William C . Thro , New York City .

’

t . J . C . Torrey , New York Ci y

u unn ff . R th T icli , Chicago, Ill

z z . E . E . Ty er, Boston , Mass

B . M . Vance, New York City .

K . M . Vogel , New York City .

g . . C . Von Glahn , New York City

m . . Windsor Wade, Palawan, P I . > B . Wadsworth, Albany , N . Y .

m R h e n . . . Wa l , Ros dale , Ka s b w S . N . Walsh, Kirk ood , Mo .

mhi e ld s . Warren, Boston, Mass > Ann h c . S . Warthin, Arbor, Mi a u n argaret Warwick, St . Pa l , Mi n.

a . H . Watters , Boston, Mass i Ch cago , Ill . a . W . R . Webster , Chic go , Ill

Lewis H . Weed, Baltimore , Md .

u . Grover C . Weil , Pittsb rgh, Pa

J . D . Weis , New Orleans , La .

i ko u . . n . . We s tte H G , Syrac se, N Y

W . H . Welch, Baltimore, Md .

C . V . Weller , Ann Arbor , Mich .

H . Gideon Wells , Chicago, Ill .

u . . . Pa l G Weston, Jamestown, N Y

G . W . Wheeler, New York City .

George H . Whipple , Rochester , N . Y .

i . Benj amin Wh te , Boston, Mass

C . Y . White , Philadelphia, Pa . l o u o . Bo der , C l

Washington , D . C . al C . Palo Alto ,

f . Stan ord Univ , Cal .

l . na W . Wi liams , New York City l Buff ao . . U. . Williams , , N Y

. S . . Willis , Baltimore , Md n B . . . Rochester , Min

nn . . K . Wi e, Jr , Albany , N Y M n z o . . . . t C Winter i , New Haven , C nn W l m . . o o . W H g , New York City

. a . S . B Wolbach , Boston , M ss

Martha Wollstein , New York City . l xvi M EM BERS OF T HE CONGRESS

n Dr . Fra cis Carter Wood, New York City . a . Wo o d tt Dr Rollin T . y , Chicago, Ill .

. . . e . Dr P G Wool y, Pasadena, Cal

. . t t . . Dr J Wrigh , Pleasan ville, N Y Z r . . e c kw e n . Dr Isolde T , London, Engla d

Dr . F . R . Zeit , Chicago , Ill .

Dr . Hans Zinsser, Boston , Mass .

AMERICAN S O CIETY OF TRO PICAL MEDICINE

r ani z e 1 0 O g d 9 3 .

V MEh IB ER ACTI E S .

. s . an a s Dr Jame E Ackert, M hattan, K n as . * . n t . Dr William Alla , Charlo te, N C . Dr Afrani n . o S t. u z Do Amaral , Pa lo, Bra il .

Dr . Charles S . Ammerman, New York City, * . u n o Dr J stin A drews , L ng Island , N . Y . u z u Ramon R i Arna , Madrid , Spain.

. f u n t Bailey K Ash ord , San J a , Por o Rico .

. u u D L . A g stine, Boston, Mass . a u Thom s Barbo r , Cambridge, Mass .

n . C . H . Barlow, Chekiang, Chi a ff M O . Nathan Barlow, Je erson Barracks , f Mil ord E . Barnes , New York City . r H . P . Barrett , Cha lotte, N . C .

n . Joh V . Barrow, Los Angeles , Cal

u n . Pa l Bartsch , Washi gton, D C .

C . C . Bass , New Orleans , La .

o . L . B . Bates , Ancon, Canal Z ne Kh l r e be . . H Beall , Fort Worth , Texas

G. . S . . Bel , New Orleans , La a B rc i z e o v t . N thaniel , Los Angeles , Cal

Robert P . Bigelow, Cambridge , Mass .

u . . Lo is F Bishop , New York City

u . r . . Lo is F Bishop , J , New York City

t . . F . C . Bishopp , Washing on , D C

u t u . R per Bl e, Los Angeles , Cal n William C . Boeck, Rochester , Min .

n o o . Sherman G . Bon ey , Denver , C l

n . . Mark F . Boyd , Ede ton , N C

L . M . Boyers , Berkeley , Cal .

Harry L . Brockman High Point , N . C .

u . Roger Brooke, Fort Sam Ho ston , Texas

u u u . Dr . Otto T . Brosi s , Barranq illa, Col mbia * u t . . Dr . C . W . O . B nker , Washing on , D C

u u . Dr . G . R . B rke , San J an, Porto Rico M EMBERS OF TH E CONGRESS l xvi i

* u . t . Dr Charles S B tler , Washing on, D C . u Dr . Fred C . Caldwell , Andal sia, Ala .

. . . t Dr G F Callender , Washing on , D . C . i r Dr Ph lip P . Calve t , Philadelphia, Pa .

i u z Dr Anton Carin , Sao Pa lo, Bra il . * Dr . Aldo Castellani , New Orleans , La . l J . H . Chambers , Brook yn, N . Y . u Asa C . Chandler , Ho ston, Texas .

. u A Pena Chavarria , Bogota , Col mbia .

Herbert C . Clark, New York City . ufu R s Cole, New York City . Hai . . te n . o f S S Cook, Cape , Rep Haiti . n n Rola d C . Con er , New York City . r u E . C . Co t , Pittsb rgh , Pa .

. t W . W Cort , Bal imore , Md . y u n Wesle Cintra Cox , Fort Sam Ho sto , Texas .

Charles F . Craig, Washington, D . C .

. t . . Eloise B Cram , Washing on, D C l u i i n Nathaniel Crich ow, T lag , Brit sh Solomon Isla ds .

Bowman C . Crowell , Chicago, Ill . hfi l . . Crutc e d E D , San Antonio, Texas .

t . Thomas Darlington, New York Ci y z Nelson C . Davis , Rio de Janeiro, Bra il .

William E . Deeks , New York City .

. r . Oswald L Denney , Ca ville , La

u . n t . . Pa l F Dicke s , Washing on , D C l e Ca . G orge Dock, Pasadena ,

. . a . W E Dove , Dallas , Tex s un G . C . D ham, Carlisle, Pa .

wr . unn i Co . La ence H . D , Ov d , Seneca , N Y .

u . Charles W . D val , New Orleans , La

W . E . Eaton, Washington, D . C . Esc o m l . e u u. E , Areq ipa, Per

. h H E . Ewing, Was ington, D . C . u E . C . Fa st , New Orleans , La .

. n T H . Fe ton, Philadelphia , Pa .

William D . Fleming, Washington, D . C . u T . B . F tcher , Baltimore, Md .

. . u W P Galbreath , San J an, Porto Rico .

W . G . Gamble , Charleston, S . C .

. . a t . . R R G sser , Washing on , D C

z . z z u Martine I Gon ale , San J an , Porto Rico

a u n. Ernest W . Goodp st re , Nashville , Ten

M . L . Graves , Galveston , Texas .

. u . Alvis E Greer , Ho ston , Texas b rl . . Gu e e t J E , Seattle , Wash . u Herbert G nn , San Francisco , Cal .

. u t . Clyde G G thrie , Cincinna i , Ohio l xvi i i M EM BERS OF THE CONGRESS

I aravid e z u z u t g G tierre , San J an, Por o Rico . 1 0 Lewis Wendell Hackett , Rome , Italy . u . t . Ma rice C Hall , Washing on , D C .

Richard P . Hall , New York City . De Funiak Henry Hanson, Springs , Fla.

t . John Harper, Washing on, D C .

. n Howard R Hartman , Rochester , Min .

J . L . Hatch , New York City . n . . ti . R W Heg er , Bal more , Md

V . G . Heiser, New York City .

. . ua u J B Helm, Manag , Nicarag a .

. . d C A Herrick, Ma ison, Wis .

Marshall Hertig , Boston , Mass .

M . E . Higgins , Washington , D . C .

A . Parker Hitchens , Manila , P . I . ff . u . W H . Ho man , Habana , C ba ff u William Ho man San J an , Porto Rico .

u . Mary Jane Hog e , West Chester , Pa

Ralph Hopkins , New Orleans , La .

Albert A . Hornor , Boston , Mass .

. u t . Henry S Ho gh on, Iowa City , Iowa

. u . Ellis H H dson , West Philadelphia, Pa

u z o . Lee S . H i enga , New Haven, C nn

. u . E E . H me , Fort Benning, Ga

. u . E H . H me , Changsha, China

Irving S . Ingber , San Francisco , Cal .

o . William M . James , Ancon , Canal Z ne

. Foster M . Johns , New Orleans , La

Francis B . Johnson , Charleston , S . C .

u u t . . L ci s W . Johnson , Washing on, D C

. Richard L . Kemel , Cartagena , Colombia , S

John F . Kessel , Los Angeles , Cal .

- . ac so vi lle , l . J Lee Kirby Smith , J k n F a

. w . R C . Kirk ood , Modale , Iowa

u . Pa l Klemperer , New York City

z . . Oskar Klot , Toronto, Ont , Canada

f . C . A . Ko oid , Berkeley , Cal

u . William Kra ss , Memphis , Tenn

Alexander Lambert , New York City .

u . Robert A . Lambert , San J an , Porto Rico

R . H . Laning, Charleston , S . C .

LaRu . . e George R , Ann Arbor , Mich

f . u . William T . Lawrence , So th Rhodesia , S A rica

Charles N . Leach , New York City .

ra . Lo s . F nk J Leavitt , Angeles , Cal

Joseph Leidy , Philadelphia , Pa . L m e ann . I . I . , New Orleans , La

A . L . Levin, New Orleans La . MEM BERS OF T HE CONGRESS l xi x

u . Moise D . Levy , Ho ston , Texas

. James F . Leys , Philadelphia , Pa * . . . . u hose , orea Dr A J L dlow, C n K

nn . . . Ke eth M Lynch , Charleston, S C

n . Ra dolph Lyons , New Orleans , La

o . . The dore C Lyster , Los Angeles , Cal

Ma N al . . . . c e orest ills , W J , F H N Y

Mc Co t . . George W . y , Washing on , D C n M Elro . n . c Joh B y , Memphis , Ten l M K nne Ca . u . c e Arth r C y , San Francisco,

Mc Le an u . Norman T . , Portsmo th , Va n Ma ath . Thomas Byrd g , Rochester , Min u Oscar C . Mandry , San J an, Porto Rico .

u s . R dolph Mata , New Orleans , La

n x . . e i g, hi a J Presto Ma well , P k n C n

z z . u . Eduardo Ramire y Melende , Habana , Rep de C ba nn Henry E . Meleney , Nashville, Te . f Maynard M . Metcal , Baltimore , Md .

K . F . Meyer, San Francisco , Cal .

u . J . C . Michael , Ho ston, Texas O . J . Mink, Great Lakes , Ill . u z J . Montenegro , Sao Pa lo, Bra il . lan Mac Far d . G . Mood , Charleston , S C .

n . u . Joh T Moore, Ho ston, Texas n William L . Moss , Bosto , Mass . u n P . F . M rphy , New Orlea s , La .

. . t . . R E Noble, Washing on, D C n un z San u Solo N e , J an , Costa Rico . ’ O Co nno r F . W . , New York City . an u n S . P . Morales Otero, J a , Porto Rico s Elmer F . Oti , Melrose, Mass . f . . . t . o . Dr G G de Paredes , Panama Ci y , Rep Panama au . . t . J C Parham, Por Prince , Haiti

. . n . t . Dr R R Parker, Hamil o , Mont n . San u George C Pay e , J an, Porto Rico .

. n t . E Peterson, Washing o , D C . t n u u . Arling o Pond , Ceb Ceb , Philippine Islands

. . f W H Pott , Nor olk, Va .

. rather , . David J P Warsaw, Poland

l E . t lliott C Pren iss , El Paso , Texas . u n P . L . Q ere s , New Orleans , La . f . an n S . Al red C Reed , Fra cisco , Cal

Edward U . Reed , San Francisco , Cal . Le e San Rice , Antonio , Texas .

T . C . Riggins , Cincinnati , Ohio . e William A . Ril y, Minneapolis , Minn. s D . Riva , Philadelphia , Pa .

t t . e t t . S ewar R Rob r s , Atlan a , Ga lxx M EM BERS OF THE CONGRESS

e a an L on rd Rogers , London, Engl d . u s Man el D . Roj a , New Orleans , La.

. t t Francis M Roo , Bal imore , Md .

. . u t s . M J Rosena , Bos on, Ma s t P . S . Rossi er, New York City .

u . u Pa l F R ssell , Milton , Mass . n . St . n t . . J Harold Joh , Washing o , D C

N . M . Saleeby, Manila, P . I . and r un . S o d . t . J H g , Bos on, Mass nf . . n A N Sa ord, Rochester , Mi n.

A . W . Sawyer , New York City . u n n o Lo is Schapiro, A co , Canal Z ne .

i . u tz nf t . . Edw n W Sch l , S a ord Univ , Cal n a z t t . . Benj ami Schw r , Washing on, D C

. . t n t . R E Sco t, Washing o D C . nn n William H . Seema , New Orlea s , La. n u n . Sa t Francisco A Seg reda, J a , Por o Rico.

. . t ass. A W Sellards , Bos on , M

. u t s . George C Shatt ck, Bos on, Mas

. n n . t . . J E Shillinger , Washi g o , D C

n n . . . t . J F Siler, Washi g o , D C

u Lo s n s . John William Sh man, A g ele , Cal

n n . . . t . J S Simmons , Washi g o , D C

n . Sidney K . Simo , New Orleans , La

i . . . t E E Sm th , Washing on , D C . n ss Lawrence W . Smith , Bosto , Ma .

Frank Smithies , Chicag o , Ill .

William F . Snow , New York City .

n z . F . L . Soper , Rio de Ja eiro , Bra il - n z uz u . H . C . de So a Ara j o , Rio de Ja eiro , Bra il

. . t t . . E R Stit , Washing on, D C

. t t . . Norman R S oll , Prince on , N J

. . t t . R P S rong , Bos on, Mass

u . Horace W . St nkard , New York City i u z u . Ramon M . S are , Sant rce , Porto R co

n . . John M . Swa , Rochester , N Y n t S O . . W . C . Sweet , Bangalore , Mysore Sta e , I dia

u . Pa l T . Talbot , New Orleans , La

f . W . H . Talia erro, Chicago , Ill

u . . . Arth r N Tasker , Washington, D C

C . E . Terry , New York City .

William S . Thayer , Baltimore, Md .

u n u . Wilb r F . Thomso , Bea mont , Texas

u t . A . Torregrosa , San J an , Por o Rico

z z . E . E . Ty er , Boston , Mass

. . t . R M Van War , New Orleans , La

u . . H . W . Wade , C lion , Palawan , P I

f . Allen M . Walcott , Lagos , Nigeria , W . A rica

l xxi i M EM BERS OF T HE CONGRESS

* n . w t ru Dr William De it A d s, Cincinnati , Ohio . * . . nt n Dr Edward W Archibald, Mo real , Ca ada. n . u u s Dr H gh A chi clo s, New York City . * . . . z n Dr A T Ba in, Montreal, Ca ada . E Dr . mil G . Beck, Chicago , Ill . * n . . t Dr Ralph B Bet ma , Chicago, Ill . * Dr . Howard L . Beye , Iowa City, Iowa . * an . . t t . Dr Frank K Bol d , A lan a , Ga Law raso n n Dr . Brow , Saranac Lake , N . Y . * nn . u n Dr Harold Br , San Fra cisco, Cal . * u Dr . Ethan F . B tler, Sayre, Pa . * . . n Dr J Roddick Byers , Montreal , Ca ada . * . . . . Caulfie ld n n Dr A H W , Toro to, Ca ada .

. u . f Dr Lo is H Cler , Philadelphia , Pa .

r . ufu t D R s Cole , New York Ci y . * l . o r l s . C o Dr Pol N y , New York City . * u Dr . Sam el J . Crowe , Baltimore , Md . * . E ut Dr lliott Carr C ler, Cleveland , Ohio . >* . . n . t . Dr T C Daviso , Atlan a, Ga H . n . o t Dr Victor P Diederich , Spri gs , Ark .

. u Do ll n . ve t . Capt Cha ncey E , For Mo roe, Va

. nh u t . Dr Kennon D am , Cincinna i , Ohio

Dr . Edmond M . Eberts , Montreal , Canada . * . t . Dr Carl Eggers , New York Ci y n . t . Dr Max Einhor , New York Ci y * n . s . Dr Leo Eloes er , San Fra cisco , Cal Y k . . o r t . Dr Charles A Elsberg, New Ci y ’ A ll . . . u t u e e t n Dr R G Ferg son , For Q p p , Saska c he wa . * n . t . Dr Herma Fischer , New York Ci y * Dr . John B . Flick, Philadelphia , Pa . * n r . Dr . Co rad Georg, J . , Ann Arbor , Mich * M . E . u O . t . Dr var s A Graham , St Lo is , * . n t . Dr Nathan W . Gree , New York Ci y * t u . Dr . Fraser B . G rd , Mon real , Canada

D r . James T . Gwathmey , New York City . * u n n nn. . t t . t Dr S ar W Harri g o , Rochester , Mi * He d blo m . Dr . Carl A . , Chicago , Ill * u . Dr . George J . He er , Cincinnati , Ohio * Dr . Charles Gordon Heyd , New York City . * Hi z r . . . t o t t D r James M , New York Ci y San Dr . Emil Holman , Francisco , Cal . *L l . t . Co . . t William L Keller , Washing on , D C

Dr . James H . Kenyon , New York City . * Dr . John D . Kernan , New York City .

. . . t . Dr Adrian V S Lamber , New York City * . t . Dr Walter Es ell Lee , Philadelphia , Pa * n n . Dr . Willis S . Lemo , Rochester , Min * S . u n t . Dr . William Lerche , Pa l , Min MEMBERS OF THE CONGRESS l xx i i i

w Leon T . Le ald , New York City .

Howard Lilienthal , New York City .

A . L . Lockwood , Toronto, Canada .

s . . Charle D Lockwood , Pasadena, Cal

Frederick T . Lord , Boston , Mass .

n . Urba Maes , New Orleans La

a i . W lton Martin , New York C ty u f R dol Matas , New Orleans , La .

Ralph C . Matson, Portland , Ore .

Ray W . Matson , Portland , Ore .

M . . c Sw e e ne E S . y , New York City

Willy Meyer , New York City .

James Alexander Miller , New York City .

r . Robert T . Miller , J . , Baltimore , Md

James F . Mitchell , Washington , D . C . M h . i z o sc o w t . Alexis V , New York City

. u George P M ller , Philadelphia , Pa . u f Harold Ne ho , New York City .

Edward N . Packard , Saranac Lake , N . Y . P arfi n . t u . C D . , Grave h rst , Ontario

Edward W . Peterson, New York City .

Edgar W . Phillips , Rochester , N . Y .

Otto C . Pickhardt , New York City .

u . Henry S . Pl mmer , Rochester , Minn

E . H . Pool , New York City . u St art Prichard , Battle Creek, Mich . u Sam el Robinson , Santa Barbara , Cal . n im . . S c r e r . Fra cis A C g , Montreal , Canada u Arth r M . Shipley , Baltimore , Md .

. . M u O . J J Singer , St . Lo is ,

John Smyth , New Orleans , La . De Witt Stetten , New York City .

. n David A Stewart , Ninette , Ma itoba .

George A . Stewart , Baltimore , Md . Th e arl . e o o . William H , Denver , C l z Fran Torek, New York City .

. u Philemon E Tr esdale , Fall River , Mass . u Gabriel T cker , Philadelphia , Pa .

Gordon P . Vinson , Rochester , Minn .

Everett E . Watson , Salem , Va .

. o o . Gerald B Webb , Colorado Springs , C l

Edward S . Welles , Saranac Lake , N . Y .

Allen Whipple , New York City . n Wyma Whittemore , Boston , Mass .

Abraham O . Wilensky , New York City . Yankaue r Sidney , New York City .

. uk John L Yates , Milwa ee , Wis .

. . ilms . J H W , Cincinnati , Ohio l xx iv M EMBERS OF TH E CONGRESS

ASSOCIATE MEMBERS . a David H . B llon, Montreal , Canada .

Frank B . Berry, New York City .

u . Edward D . Ch rchill , Boston, Mass

Dean B . Cole , Richmond , Va .

Dan Collier Elkin, Atlanta, Ga .

u . James Greeno gh , Cooperstown , N Y .

Frank S . Johns , Richmond, Va .

Hertel P . Makel , Washington , D . C .

Alton Ochsner , Madison, Wis .

Chester M . Van Allen , Chicago, Ill .

H ONORARY MEMBERS . l Edward R . Ba dwin , Saranac Lake , N . Y .

Alexis Carrel , New York City . u MO Norman B . Carson, St . Lo is , . De h e ll Georges y Le Havre , France . f Al red Meyer , New York City . u n f S . Adolph s K op , New York City .

E SENIOR MEMB RS .

B ran r o we . William , New York City

u . Armistead Cr mp , New York City

n . t . Joh A Har well , New York City

Chevalier Jackson, Philadelphia, Pa .

Howard A . Lothrop , Boston , Mass .

t . Morris Manges , New York Ci y

. u Charles L Sc dder , Boston, Mass .

. t . William H Stewart , New York Ci y

The following were present as VISITORS

u f to vario s o the component Associations .

uff A . H . Aaron , B alo , N . Y . Al a . s tt Rodney F , Santa Barbara , Cal . u D . W . Ayer, Syrac se , N . Y .

Franklin G . Balch , Boston , Mass .

Frederick R . Barnes , Fall River , Mass . u Edward L . Ba er , Philadelphia , Pa . u J . A . Ba er , Hamilton , Canada .

u . Robert W . B ck , Boston , Mass

F . G . Bingham , Boston , Mass .

u u z Br no Bloch , Z rich , Swit erland . MEMBERS OF THE CONGRESS lxxv

u Dr . Noble R . Chambers , Syrac se , N . Y .

. . d . Dr F . A Chan ler, Chicago, Ill

ff . Dr F . C . Cli ord , Toledo, Ohio

l rn . . . Co ubo Dr John B g , Boston, Mass

u . . Dr . Pa l C Colonna , New York City

Dr . H . E . Conwell , Birmingham, Ala . Mar h fi l s e d . Dr . L . A . Copps , , Wisc f Dr . Rena Craw ord , New Orleans , La . T u M O . . C . Darrow , St . Lo is , ff Levin Davido , New York City .

u . Arth r Y . Davis , Erie , Pa

R . B . Deane , Alberta , Canada .

Joseph P . Derby , Springfield , Mass .

u . H . R pert Derome , Montreal , Canada

William B . Doherty , New York City .

u . C . W . Dowden , Lo isville , Ky Enz r u . e . N , Milwa kee , Wis

u . Roy Farq harson , Boston , Mass N e w . H . Finkelstein, York City

Charles F . Fisher , Brooklyn, N . Y .

J . C . Foshee , Grand Rapids , Mich .

u . L . W . Frank, Lo isville , Ky

Joseph A . Freiberg, Cincinnati , Ohio .

u . J . F . F lton, Brookline , Mass

Evans G . Galbraith , Toledo , Ohio .

W . E . Garrey , Nashville , Tenn . ff u . . Clayton W . Greene B alo , N Y

u . . Arth r S Griswold , Bridgeport , Conn

u t . . C rtis Lee Hall , Washing on , D C u F . C . Hall , Chestn t Hill , Mass .

Edward S . Hatch , New Orleans , La .

R . N . Hatt , Springfield , Mass .

B . J . Hein , Toledo , Ohio . n 0 . . Myron He ry , Minneapolis , Minn u John Hepb rn, Toronto , Canada .

Harold L . Higgins , Boston , Mass .

George A . Hopp , Philadelphia , Pa . u f James W . P . H nter Nor olk, Va . u J . M . H tcheson , Richmond , Va .

Robert H . Ivy , Philadelphia , Pa . uf Joseph Ka man , Montreal , Canada . Ke arvin M u O . William , St . Lo is ,

Henry Keller , New York City

. . f C C Kelly , Hart ord , Conn .

. . f E R Lampson , Hart ord , Conn .

Carl D . Lawyer , Providence , R . I .

. ff . u . . Francis D Leopold B alo , N Y u Lo is Levy , Memphis , Tenn . lxxvi M EM BERS OF T HE CONGRESS

MO A . J . Lorie , Kansas City , . u Harold H . Lo cks , Peking, China .

. u . William O Markell , Pittsb rgh , Pa M u CP . . Ma rice, Philadelphia, Pa M i r . e tt e . Stacy R , San Francisco, Cal MEvi . c tt . J . S , Akron, Ohio M Kin r . c st u G . H y , Pittsb rgh, Pa . f J . R . Miller , Hart ord , Conn .

George Milles , Brooklyn , N . Y .

N . C . Montgomery , Montreal , Canada .

G . H . Moore, Philadelphia , Pa .

u u . R . A . Moore, Col mb s , Ohio

John J . Morton , Rochester , N . Y . u Seeley G . M dd , Los Angeles , Cal .

u t . . S . B . M ncas er , Washington, D C u J . M . M rray , Ottawa , Canada .

u uk . F . D . M rphy , Milwa ee, Wis u u G . I . Nelson , Col mb s , Ohio . li ni k O e c . a . j , B oston, Mass

E . D . Oppenheimer , New York City . n uff . t Frederick J Parme er , B alo, N . Y .

. . t u . A J Pa ek, Milwa kee , Wis

u . u z . Sam el M Peck, Z rich , Swit erland

George Perkins , Boston, Mass .

E . T . Plass , Iowa City , Iowa .

Harry Platt , Manchester , England .

H . F . Pride , Memphis , Tenn .

ff . E . . J Radcli e , Rome , Ga

u . u . B rrell O Ra lston , Los Angeles , Cal

R c h m an . . . e t A N , Philadelphia , Pa

W . G . Reilly , Montreal , Canada .

E . . t . . C Rice , Washing on , D C

. W . W . Richardson , Mercer , Pa f F . C . Rinker , Nor olk, Va .

. u . . L A . Ro nd, Providence , R I

John C . Shrader , Fort Dodge , Iowa . f R . E . Starr , Hart ord , Conn .

Robert M . Stecher , Cleveland, Ohio .

u . D dley C . Smith , University , Va

f . . t Daniel M Stie el , Detroi , Mich f n . t . Harry F S oll , Hart ord , Con

J . B . Stone , Richmond , Va . u James M . Strang, Pittsb rgh , Pa .

. u z . Marion B S l berger , New York City f Wallace N . Sweet , West Hart ord , Conn .

J . A . Talbot , Washington, D . C .

St . . Clair Thomson, London , England

Harry L . Ulrich , Minneapolis , Minn . MEMBERS OF THE CONGRESS l xxvi i

William Penn Vail , Blairstown , N . J .

C . A . Vance , Lexington , Ky . Fai rfi l e d . Groesbeck Walsh , , Ala

John F . Ward , Manchester , England .

. . u al er . . P B W k , New Br nswick, N J

Webb W . Weeks , New York City .

Thomas F . Wheeldon , Richmond , Va .

N . L . Williamson , Montreal , Canada .

Richarda Williamson , New Orleans , La . f James C . Wilson , Hart ord , Conn .

James E . Wyant , Philadelphia , Pa . ff John Wycko , New York City f n Robert M . Yergason , Hart ord , Con . u Charles W . Yo ng , Newtonville , Mass . Ze rfas In In . . d . L G , dianapolis ,

RECAPITULATI O N .

Em e r t s en o r i u , S i , Ac t i ve and Co rre n i n no ra P re e nt xatw s e . o r . s Asso c . p d g H y American Ophthalmological Society 1 85 American Otological Society 1 38 American Neurological Society 2 03 American Gynecological Society 1 00

American Dermatological Association . 94 1 1 8 American Laryngological Association . American S urgical Association 2 1 7 American Climatological and Clinical Association f Association o American Physicians . Ameri can Association o f Ge nitO-Urin ary S ur geons American Orthopedic Association American Pediatric Society American Association o f Patholog ists and Bacteriologists American Society Of Tropical Medicine American Associ ation fo r Thoracic S urgery

Total membership Of Congress Guests and Visitors

Total attendance

T L H EOBA D SM ITH , M . D .

u n t t t t n u In septic s rgery had already pe e ra ed hrough wes er E rope . 1 880 Pasteur began his work o n Chicken cholera and anthrax vac c i In 1 8 6 K c n h nation. 7 o h had demo strated t e cycle of th e anthrax bacillus from spore to spore in a drop of aqueous humor under a n 1 881 . I t th e use tu coverglass he firs described of solid cul re media , n n u t t a d t th e use t n. nt s ch as po a o , i roduced of gela i These e erprises represent th e total Of precise kno wledge concerning th e causes O f In h infectious disease at that time . t e early eighties th e medical “ ” t nt t nnn to O f th t s ude was j us begi i g hear e germ heory of disease . There is no occasionbefore anassembly like this to review th e prog O f n n t n n ress our k owledge si ce his early period . I eed o ly mention th e t n and u tu n t n n th e isola io c l re of ma y pa hoge ic microorga isms , study of acquired resistance to disease and th e antibodies associated t it n and n t n th e wi h , of a aphylaxis hyperse si ive ess , rise of chemo therapy and th e development of our knowledge of th e protozoanand

- ultra microscopic world of infectious agents . n t to th e n t nt th e n t t Givi g bir h co cre e achieveme s are co cep s , heories

nd t e s in t t in n t th a hypo h es , which par rue , part false , a ima ed e workers and s upplied th e energy which was to bring forth th e next crop of n ne w and u nt un t . t a d freq e ly looked for fac s These heories , held

n t n th e nu u so - d defe ded by some mas er mi d , formed cle s of calle

t u th e t th t schools . The schools persis ed beca se heories for e ime n t n T O- tt bei ng were beyond demo stra io . day we hear li le of schools because eventh e most esoteric doctrine is very soondissected by ne w and adequate technique and th e school tends to dissolve be fore it has t time to gather adherens . It may be well o n this occasion to recall some of th e guiding theories which have s urvived and crystallized into actual facts and h n n n t t e u t o n i u t t . pri ciples , for hey form fo da io wh ch my s bj ec res s Inth e early days O f th e ne w era infectious diseases were looked upon n as straight contes ts between host and i fectious agent . The micro n nt u t and and orga isms e ered , m l iplied , were checked killed , or else n t t in n n th e host succumbed . Now we k ow ha ma y diseases a ki d of equilibrium establishes i tself in which th e microorganism remains somewhere i nth e host and is ready to multi ply again when th e host

In t t n in th e is o ff guard . o her diseases localiza io s occur which n t specific bacteria multiply a d survive for a time . The vic ims of n f these conditions we no w call carriers . The co cept O carrier was n In th t a developed chiefly with th e protozoa diseases . e bac eri l dis eases it first took root when th e intensive study Of diphtheria was T HE E L E OF D C I N I NFECTIOUS DISEASES .

n — forced by th e discoveries of toxina d antitoxin. The so called focal n t n n t t nt i fec io s are o ly ypes of carriers , for hey represe local forms h of disease tow ards which t e host is partly immunized . Coupled w ith this clinically serious problem O f continued localized infectious processes i s th e o ne once actively debated whether th e t u th e u n E t e x e ri iss es of pres mably ormal body are sterile . labora e p nt to t t t u t n u u n h me s were made es his q es io . As s al whe t e tech nique is no t secure from criticism th e interpre tation of results fol n n i u n . n t nt n lows i divid al lea i gs S o his co roversy . We o w know t t u t n t ane ro be s nt i n ha vario s bac eria , o ably spores of , may mai a t t inth e t t ut u t n hemselves for a ime sys em wi ho m l iplyi g . They may nt t u un th n and u u e er hro gh fresh wo ds of e ski m co s membranes .

ni n th e t t t t u th e t t The liver , drai g diges ive rac hro gh por al sys em , O t n nt n n nt t n n more f e co ai s orga isms of i es i al origi . The bacteria are n n a t t . to always very scarce whe prese all They , however , serve e xplain certain rare complicati ons following surgical operations and u n n t n in th e n t n ri ary i fec io s abse ce of o her ma ifest causes . Th e n t in t n n n co cep of carrier is i self complex , i volvi g as ma y pos sibiliti e s as th e n O f u n in th t microorga isms capable s rvivi g e issues . t n n t n th t There are cer ai hardy species which remai wi hi e sys em , others only o n or in th e folds and glandular structu res of mucous n mem bra es . Our civilization is continuously creating ne w lo c i m ino r e s in th e body and no o ne c an foretell what modifications no w - n n t n t n un well k ow pa hological co di io s may dergo . There is perhaps no o ne subj ect inth e domainO f pathology of such importance as th e problems involved inth e defense developed and

nt n th e n t n n n n mai ai ed by body agai s i vasio of foreig livi g matter . Its importance h as been recognized from th e very beginnings O f th e

t n no n bac eriological era , si ce field has bee more industriously tilled nt l t n t i s no w un B n experime al y ha wha called imm ology . efore a y headway had beenmade i nth e analysis O f disease processes associated with infecti o n numerous att empts were under way to protect th e n t ’ bod y agai st hem . The remarkable success of Jenner s cowpox n n an n u t nt n t n vacci e lo g before y orga ized , s bs a ial i ves igatio o f infe c t u n t t d t u t t n io s diseases had bee s ar e , s im la ed Pas eur to u dertake tu in n n n s dies fowl Cholera a d a thrax . Si ce that time there h as been no e nd to th e procession of methods for th e protective inoculati on agai nst disease . Here as in other fields empiricism was far in advance of organized scientific inquiry and harvested some notable t n nt riumphs of perma e value . L THEOBA D SM ITH , M . D .

It was in 1 884 that Metchnikoff published his first paper o n In t n n i phagocytosis . a disease of a small crus acea occurri g n an aquarium he saw th e spores of th e microbe as they penetrated into n n n u n th e body surrou ded a d e g lfed by wa dering cells . This ne w theory o f cellular defense was highly intriguing and kept all working ininfectious diseases busy unearthing ne w data to support or contro O f nt t n u n o f vert i t . The discovery a i oxi as a p rely humoral age t defense in 1 890 added to th e interest in that th e controversy no w n h n n f n waged arou d t e relative sig ifica ce O f these two modes o actio . Since then we have learned that th e processes started by invasive organisms in th e body are a series of highly compli cated biological

t n no o ne o f c an n t t n reac io s , which be ge erally credi ed wi h bei g pro ff n t u in te c tive o r o e sive . Thus phagocy ic cells may take p bacteria n e h n large umbers regularly y t t e process prove i variably fatal . t t o f n t n t t and Pro ozoa make a special y livi g wi hi cells , bo h epi helial n n n t t h a n t t e t . wa deri g, duri g por io of heir cycle wi hin hos The phylogenetic Significance of th e group O f mobile and mobilizable cell types was referred by Metchni koff to ancestral processes of nutrition nt t n t n in in very low fo rms . Subseque specializa io owards defe se th e animal series was scarcely capable of meeting success fully th e many diverse invasive organisms and th e defending cells actually in n n n n n became s o me i sta ces a support a d comfort to th e e emy . O th e other hand th e theory O f hum oral defense encountered an equal amount o f co ntradicto ry evidence concerning th e bactericidal ac tiv

h o t n n n ities of t e blo d . We are hus co strai ed to ack owledge that while we know a large number of interesting cellular and humoral t n and t n a no t e t a n to t t t ac io s reac io s , we h ve y le r ed piece hem oge her t t for any o ne disease satis factorily . The ask herefore is still before us to study each host—parasi te relationi ndetail and avoid generaliza t n t t u t n t nt th ff nt t o f io s , excep as s im la i g hypo heses , u il e di ere ypes n n t reactio s have be e studied compara ively . Aided by studies in genetics we are beginning to understand that we cannot add to th e original dower Of capacities we received from n t t n o ur ancestors . Medici e may assis grea ly by determi ing th e maximum capacity O f these innate powers and furthering them by It nn t h e t t adequate stimuli . ca ot add o t capaci y to produce pro ective bo d ies through vaccinationbut i t is inpositionto stimulate and mobi t lize primary late nt protective energi es . For unately individuals of th e same species d o no t diff er among themselves to such a degr ee to u nt t O f n t n but it u t as j eopardize c rre me hods vacci a io , m s always T HE DECLINE OF I NFECTIOUS DISEASES . 5 be bo rne inmind that towards any infecti ous disease a few individuals may be inadequately provided with a capacity to protect themselves even under maxi mum stimulation by vaccination procedures . It is still a question whether th e im muni ty or suscepti bility of individuals is correlated with any anatomical or physiological charac r In n th n u nt t n t at te . ge eral e impressio acq ired by experime a io is h relative s usceptibility is a character by i tself and no t predictable from

It n u t to n t a other bodily functions . has bee c s omary speak of a ur l n u unt t n d e fi as disti guished from acq ired imm i y . Cer ai species are hi nite ly immune to diseases to w ch other species succumb . This type of immunity is probably dependent o n quite diff erent factors from

t n n f u t In th e that possessed by resis a t i dividuals O a s scep ible race . latter th e immunity evidently depends o n th e capacity of th e individ ual to reproduce and mobilize certain protective antibo d ies quanti I th n m un n n l e t t o t . tati ve y . n a urally im e species hese are eeded n h n Man an Metabolic proc esses probably co trol t e Situatio . d all animals have a certain fundamental resistance even when th e race has no t been in prolonged contact with th e specific microorganism since dosage of virus makes a great diff erence i n th e outcome of all n nt t nt th t u inoculatio experime s . Wha is really mea by e erm acq ired immunity is that th e indi vidual has simply strengthened or aug m e nte d his ori gi nal resistance in th e presence O f specific infection. This Changed state is usually indicated by an increase in certain n a tibodies . As a corollary O f th e various established laws in immunology i t has bee ngenerally accepted that th e ani mal organi sm is a unity inits n n n a ff t nn ’ efforts to protect a y tissue or orga . The ge er l e ec of Je er s local vaccine pustule must have forced this principle forward long but t th e tt n th t n t ago , wi h spli i g up of e prac ice of medici e hrough necessity into specialties dealing with individual organs this funda n nt m n me tal law may be easily lost sight of . The developme of im u ology h as however accentuated th e fact over and over that any local multiplication O f infectious agents tends to spread its influence

h nt n t alle r i z h through t e e ire system . A Si gle small ubercle g e s t e nt u nt th u whole body . A ibodies are po red i o e blood so q ickly that th e higher local immunity produced by inoculation c an be distinguished n t t f t at t n th e n o ly wi h grea di ficul y, i f all , from hat pervadi g orga ism as a whole . Next in impo rtance to th e concept O f im munity is that of th e f i o b h variability O m cr organisms . The period efore t e eighti es O f th e 6 L THEOBA D SM ITH , M . D .

‘ last century wi tnessed th e publicationof what we would to - day d e sig nate as very wild theories o n th e changes which microorganisms may

n n th e u dergo . O e of earliest writings of K och i s direc ted against ’ a book of Nag e li s i n which among other things it i s stated that th e nt u e t i n ut n n a hrax bacill s b comes a saprophy e p refyi g a imal tissues . TO counteract these heterodox assumptions K och and his followers became rather to o rigid adherents of th e theory O f th e stability Of n It u h pathoge ic bacteria . req ired some time therefore for t e newer

a o f t t e t t t ide s variabili y o g a foo hold . Slowly ma erial accumulated which proved that no pathogenic microorganism was without vari n u and h n a ts . The so rce origin o f t e ma y varieties of th e same

species remained Obscure . We know that bacteria gradually lose their virulence or mutate into almost no n-virulent types under condi

t n O f t tu but n o t io s ar ificial cul re this decli e is t be expec ed . This is diff erent from th e variations observed among microorganisms pro d uc ing th e same clinical disease and no t y e t influenced by artificial u u t n n t n n c lt re . The varia io s amo g pa hoge ic microorga isms are prob n h n n n t n in h ably i duced i h t e huma a d a imal body . Mee i g t e tissues a

t t th e t t t t t varie y of obs acles , parasi e mus adap i sel f or else cease mul i

I t t ff n O f plying . t is highly probable ha serological di ere ces micro organi sms otherwise closely related biologically are th e result of h interaction between them and th e host ti ssues . T is capacity to

undergo modificationwill be touched uponagain. The variability of microorganisms meeting a Similar variability in th e natural and specifically augmented resistance O f th e host produces

ur t n a certain relativity which occasionally defies all o s a dards . The intimate association of th e newborn generation with i ts immediate n t n t th e t t n n e t nt a ces ors a urally favors direc ra s fer of i f c ious age s , chiefly mucous membranes parasites carried usually with light sy m p

r n h t tu t toms o no e at all by t e adul s . Na re has provided a par ial safeguard in th e placental transmission of antibodies to pro d uce a

t r Int nt empora y passive resistance . hose species which have place as h u to th e t t nt t e t u t n t t . impervio s pro ec ive a ibodies , colos r m ra smi s hem In experiments carried o n for some years o n o ne of this latter

th e t t n ff a th e n t n group , remarkable pro ec io a orded c lves by i ges io of colostrum has been demonstrated by replacing it with ordinary

n n t n Bac i llus c o l n th e mi lk . U der such co di io s i is as virule t as In anthrax bacillus in later years and produces a fatal septicemi a . th e partially protected a latent microbism establishes itself and i t may n t t t u t th nt in t t t ma ifes i self la er p o e third mo h o f li fe mul iple ar hri is , THE DECLI NE OF I NFECTIOUS DISEASES .

n to t n n and t ff t . nephri is , p eumo ia , possibly o her a ec io s The door these invaders is probably closed as soon as peptic digestion is well n B t t C t u th e . t established . efore ha olos r m fills gap The place al t ti n t t u u t mode of pro ec o , for ified perhaps by colos r m , m s have played an important r Ole am ong prim itive people in safeguarding th e very n n ti n at t n t t t O f young against e demic i fec o s , leas agai s a fa al ou come u t t t t t o n th e same . These res l s Show ha bac eria harmless la er may n t h n u t t t seriously cripple and eve des roy t e you g . They also s gges ha B ac illus c all may at some early period have produced a cholera similar h - to that associat ed with t e cholera vibrio to day . AS a result of th e impact O f th e ne w concepts derived from micro biology th e medical mind turned to a large degree from th e idea of t to n t n t n h e t t O f nt n. F cure to ha preve io irs , check i fec io by s oppi g t

i n to n t n n t transfer of m croorga isms from Sick well , disi fec io domi a ed i t preventive medicine for many years . Th s phase led to a grea development of public health agencies and th e entire public health service with i ts water supply and sewerage systems and i ts multi i n nt n tud no us i spection of food products . The idea of preve io came n t thus with full force into medical practice . The physicia expec s no t so much to cure as to prevent th e disease from taking th e next n t to nt t nt t n n th e u dow ward s ep , preve dis a localiza io s by keepi g vir s in its original attacking place until developing imm unity takes a t n h hand . The fu ure the evenof th e next day or t e next hour became th e Obj ect of inquiry S O that i t might be adequately m e t and th e n n untoward processes che cked . Preve tio implies th e study of causes o r necessary antecedent conditions no t only between health and d i s ”

but t n t th e a t and th e n x t n ease, be wee each s age of dise se i self e , he ce th e modern craving for more informati on concerning th e earliest

t . n tt n t n t n in th e s ages We k ow very li le , i f a y hi g, of what ra spires

n u t n so nt n o ff th e t C n i c ba io period , defi i ely fe ced from firs li ical Y mani festations . et it is conceivable that inthis stage th e fate o f th e t nt t t n pa ie if lef o himself may be diag osed by refined studies . n t n t h T U for u a ely t e difficulties are great . o trace th e entry and local behavior of a few mi crobes at th e start is a far more trying under t n t n to o th e t O f i in th aki g ha foll w exi myr ads e recovering host . The presence o f minute amounts O f protective substances o r O f toxins in th e early stages is probably beyond th e detective capacity of pres n t t e t labora ory me hods . Two types O f procedure in th e scientific inquiry into disease pro nt o ut O f th e O f n F t t n. cesses have defi i ely come idea preve io irs , 8 LD TH EOBA SM ITH , M . D . inquiry into th e causes and antecedents O f disease uponwhich is based n n n di h t t to t . s t e public heal h moveme elimi a e them Seco d , empiric c o ve r t and t O f th e n to n t y , largely by rial error me hods , mea s eu ralize

th ff t a n t n and t . e e ec s of causes , such as v cci a io chemo herapy These two nt nt t t t t moveme s are i ima ely associa ed , so much so ha we hardly

n i o ne t n to rt in no t n nt k ow wh ch we are ryi g fu her research , i freque ly h n n both at t e same time . Spri gi g from them are tw o currents governed by distinct attitudes o f mind : The first endeavors to bring th t o i t and n nta e race back owards earlier, m re prim ive more fu dame l modes o f li fe under which i ts evolutiontook place . The second tends to develop substitutes for these and to permit us to involve ourselves in n n more completely our artificial e virome t . During th e half century of microbiological dominance th e rise of

r n I special workshops o laboratories has bee phenomenal . t wo uld be difficult to exaggerate th e part played by th e pure culture of bac n teria upon th e establishment of laboratories . It fur ished readily t o a large number o f workers a single isolated living factor with

n nt t t th e t t n and which to experime t . Co ras ed wi h complica ed ech ique

nt th e t t t o f th e t t equipme of physiologis , ha bac eriolog is was simple n u n f - h a d readily reprod ced almost a ywhere . The same is true o t e

n t th e t t O f immu ological labora ory , special ou grow h microbiological In t n h n n h research . evalua i g t e fu ctio s o f t e research laboratory we in n i t t n It u t must bear mi d ts limi a io s . sually deals wi h more or less t nt n t n u w in exaggera ed , i e sified ypes of i d ced disease , hereas medical practice much material represents th e terminal or hold — over stages o f

n t u t f u t to w t t uti . i fec io s processes , hose most di fic l deal i h herape cally t t n t n th e e The labora ory deals wi h mi imal frac io s of blood , for xamp le , whereas th e body utilizes th e enti re blood through rapid circulation. Res istance is thus frequently demonstrable clinically when tests of minute samples of blood fail to reveal this resistance because of th e

In t nt c an apparent absence of antibodies . fact hese a ibodies be brought within th e range o f laboratory methods only by procedures ni of hyperimmu zation. n It un t to n The laboratory fu ctions i n two ways . der akes a alyze th e complex phenomena of nature as perceived by th e senses with th e n I m a t aid of methods and instruments of precisio . t thus y depar

th i n t n to th e n nt its from e problem as a whole , propor io refi eme of ni In n i t n i t . t t t t ech que fac , hrough ar ificial mea s simply ga hers i div d h n n n n I ual facts to aid i t in th e final study of t e atural phe ome o . ts second function is to imitate th e complex natural phenomena as

I O L M. D TH EOBA D SM ITH , .

ni sh in th n t n no t n t g e i fec io may eve be ou wardly diseas ed . This local or geographi cal immunity is especially marked i n th e protozoan

t it t t n t . diseases , al hough exis s owards all i fec ious diseases As to th e great epidemics which tend to sweep rapidly over large ’ th e t u t t th e u n areas of ear h s s rface, I believe ha ca sal orga isms have n n n n ff a special history . They have come from a e viro me t di erent from that into which they are launched whenthey produce widespread a i n t th nt t n . e t t nt th e disease Le v g hem for mome , we may call a e io o general law of natu re that to o virulent races o f microorganisms may become extinct because th e host perishes before th e period O f e xc re n t t n . O n io begi s her microbic races the take their place . These are probably th e result of th e interaction between host cells and fluids and th e i n u n i t m croorga ism by which vir le ce s sligh ly reduced . The e nd result is thus no t only a slight rise in th e specific resistance O f th e population but an adaptation o f th e microbic cause to living c o n d iti o ns in th e ne w host which means virulence lowered to a certain

. t t n th equilibrium level Af er his has bee reached , provided e micro

n O f th e i t n th e orga ism is capable requ red modifica io , disease becomes n m n ut I t e demic with s all e demic o bursts from time to time . t is his form of disease in which gradual reduction in mortality has taken n n n place a d i which econo mi c and medical influe ces play a part . The larger pandemics are in a meas ure checked by quarantine and is o la tionbut th e progress of th e infectious agent is usually so rapid that th e barriers are p ut up after th e entry of th e virus and th e epidemic n n r t w n. goes i ts way more o less u checked . These fac s are well k o The o ne addition I s uggest is th e gradual o r more accentuated modi

fic ati o n o f th e nt t t t t epidemic virus i o a more rac able , less des ruc ive

n n to tu n to i ts n n . orga ism , probably ever re r origi al level of virule ce

V t n th e o f th u n iewed from his a gle, flora e muco s membra es may be either th e degenerated survivors o f recent or ancient epidemic types i t or else saprophytes adapting themselves to th e parasit c sta e . As n B l l t at nth e t u ac il us c o i t . already hi ed , eve ubiqui o s may have a his ory

n t o f th e n o ri i nat The i fec ious diseases huma race , some probably g in i nits n n t and o nto t m an g a imal a ces ors passed primi ive , developed n o n in an environment equivalent to that of animal life . Tra smissi

O f n t n nt t and t was t t t t i fec io by co ac o herwise immedia e , direc , wi hou

t n u ut n t n n t o r t . dis a t circ mloc io s hrough milk, dri ki g wa er s ored foods The virus was fresh and uninflue nc e d by prolonged exposure to n n n n nt ff n t . e viro me al age cies There was , however, a Sig ifica di er ence betweenth e p rimi tive and th e Civilized groups . The former were I I THE DECLINE OF I NFECTIOUS DISEASES .

- n n h e n n t . essentially static ; t moder primarily mobile , eve ear h e circli g m an and n t ff nt n t u In th e early history Of his a ces ors , di ere i fec io s n ff n t h u agents probably arose i di ere t par s of t e globe, m ch as a dis ti nct fauna and flora characterized th e various continents and smaller n n n o n unt o f isolated areas . They remai ed more or less co fi ed acco n th e li mited capacity Of m an for going long distances . Eve migra tions and wars were slow in progressing and diseased individuals may have been left beh ind or they may have succumbed o n th e way . The discovery and use of any means of rapid transportation might have beenhighly destructive or even fatal to th e early races of m an n t f n to n t t t m an in kind . A o her di fere ce be o ed is ha early lived close contact with his domesticated animals and with many untamed n u t n o - n species both of vermina d game q ali y . Eve t day amo g people of th e Far East th e domestic animals are housed under th e living quarters . In O f t c t th e t n t th l t view hes e fa s ques io arises , wha are e possibi i ies for th e appearance of ne w or mo d ified typ es of infecti ous disease when microorgani sms trans ferred to another Species change their physiological character more o r less and accidentally become through thi an n t t n n m an? t t s ch ge , i fec ious for o her species , i cludi g Tha his o f t n n th e n ani process hos cha ges is respo sible for ma y microorg sms , C t to o ne n t e e t no t t nt m to losely rela ed a o h r y absolu ely ide ical , see s me i t highly plausible . We are fam liar with hree races of tubercle n n bacilli . They are probably derived from some o e a cestral typ e . TO what extent has each o ne reached th e limit o f i ts capacity to become modified in another host ? Or is i t still possible that under

n t n n n r n n t n special co di io s , realizable o ly u der a ve y u usual combi a io nt th e n t t n? E nt Of eve s , bovi e ype migh become huma xperime s have thus far negati ved this but experiments are limited in combinations and time whereas innature th e number o f opportunities and th e time nl are u imited . While many factors working in primitive times to bring ani mal infecti ons within th e daily reach o f m an are no w eliminated others t n t th e t t have ake heir place, such as ex reme mobili y of modern life n n t t nt th nt n bri g i g oge her eleme s from e e ire globe . This is evide ced th e nt t n O f n t t and nt by rapid i roduc io i sec pes s pla diseases . There are evenno w a number o f animal diseases capable of producing ser u in m an but t in t n n io s disease , here is all some hi g lacki g, except in n n to t th e inm an n p eumo ic plague, comple e cycle a d make it a human

. n t t th e th n t n disease The a imal s ill ac s as reservoir of e i fec ious age t. I 2 L M D THEOBA D . SM ITH , . .

- n n n t o f c t The well k ow pa demic ypes disease, su h as Asia ic cholera and n u n in th e t t w t Eu i fl e za , which have pas repea edly s ep over rope and th e n nti n nt n reached America co e , come from regio s where primi n n h h n t n tive co ditio s are t e rule . Here t e orga ism wi h pa demic pos sibiliti e s may receive i ts preliminary training in ani mal species and n i t nd t n n n eventually reach m a . That t always exis s a is kep co fi ed o ly

h n t o f n by quarantine is t e usual expla ation. The his ory a im al

r nt t nt ti t th e t plagues hardly wa ra s his as e irely sa sfac ory, for grea pandemics appear to have a potentiality whi ch defies quarantines and vaccines .

u t ti nO f t th e nt o r n A good ill s ra o my heme is rece , more less sudde , sporadic app earance O f undulant or Malta fever at great distances i t h t n n In fro m s supposedly primary center about t e Medi erra ea . stances o f this Clinical complex have be en reported within recent n in th nt t t n years from various regio s e U i ed S a es , from De mark,

n n R n o f i n an o t G a d . t d erma y, hodesia The umber cases I aly her n t nt endemi c regions appears to have i creased . How are we o accou fo r these o c currences ? The organism O f Malta fever in goats has n t n been recognized si ce 1 889. The closely rela ed form produci g n An n abortionincattle si ce 1 897 . other race inswi e was first recog

z 1 1 It t t th e n t n ni e d in 9 4 . is my belief ha porci e varie y has bee developed from cattle in recent times in th e Middle West as a result o f th e very Close association o f th e two species in th e feed lots and th e adaptationo f th e bovine variety to th e pig under certainunknown

n n th e n t n n nt in co ditio s . I f bovi e ype is respo sible for u dula fever m an i t t t n u t to t t n , why is ha such cases have bee bro gh ligh wi hi

o r u n to n in three fo r years , whereas accordi g evide ce developed my o wnwork this microorganism was active indai ry herds inthis country as far back as 1 893 ? Since thenprobably every o ne who has drunk i n t i ni n o r n t raw m lk has i ges ed th s microorga sm o ce ma y imes . Is i t that th e hospital laboratory has completely overloo ked i t during these 35 years and has medical practice so many erroneous diag noses to answer for ? My o wn tentative explanation is that the I a th recent cases come from several sources . t is probable th t e n o n n at t n in bovi e rga ism is o ly feebly, i f all, capable of mul iplyi g th e n t t t O f t t th huma sys em , ha passages his race hrough e pig have made i t more vi rulent for m an and that some o f th e modified p o r cine races in o ne way or ano ther have gottenback into th e udder o f i n nt I some cows establish g small ce ers of human disease . t may 1 THE DECLI NE OF I NFECTIOUS DISEASES . 3 also be that th e caprine or true Malta fever variety has been spread nt about in ways I need no t go i o here . I f nothing had beenknown of th e ani mal diseases furnishi ng this humaninfectionwhat would have been our speculations o n this ne w disease ? We should have regarded it as no n- infectious since i t t n t t u n does no t pass to contacts . We migh have i ferred hat mos h ma beings are immune and that some are potential carriers . We should probably have failed to turn to animals as reservoirs owing to th e h n filt rable no n f an t C . t e absence O y direc lues I f e virus had bee , n t t th e n u n nt n a d t n . cul ivable , dark ess wo ld have bee i e se persis e Concerning th e disease in m an several questions at once present

Bac i llus abo r tus th e t to n t t themselves . Does possess capaci y pe e ra e into th e system but without being able to multiply until some condi tions arise depressing or perhaps exalting certain functions whi ch permit th e micro o rganism to multiply and call forth symptoms o f undulant fever ? It is obvious that a few bacteria in th e normal system would only by accident appear o r be sought for incultures of n n i t n nti t n u tu t o t . blood . A body produc io wo ld a rally wai mul plica io Bearing in mind th e fact that th e bovine race o f Bac i llus abo r tus is n t n in ’ a t t t t k own o have bee cows milk t leas for y years , here is s ill n th n another explanati onwhich deserves consideratio . I f e appeara ce o f undulant fever should prove to be recent and i f it c anbe traced in ’ some Of th e cases to th e bovi ne type of Bac i llus abo r tus in cows t n l n in th e n t t n o f th e milk, here may have bee a dec i e a ural resis a ce

n nt t n th e o un t o n nt race, a decli e e irely wi hi b ds of probabili y accou o f th e changing mode of life and th e gradual elimination of natural n selectionwith refere ce to infectious diseases . Taking these facts into considerationand th e increasing number of ne w trials opento microbes to become established inne w hosts made possible by th e continuous flux of an increasingly dense population o f o t u n and n t t t b h h ma a imal species , domes ica ed or merely parasi ic o n n t n ti t n i n to vi co di io s produced by domes ca io , we may beg sualize th e t ne w possibili ies for diseases to appear . They might come more or less suddenly when conditions are rapidly altered as in war for m an and in e n r n f n , r ari g la ge umbers O a imals i n confinement with and e nt ni t n t t regular frequ commu ca io wi h o her similar populations . We may readily conceive of th e many changes in infectious organ t th isms par ly accomplished , followed by e destruction of th e ne w n t n no t an race because some co di io s are fulfilled , d hence th e many

t th e t ne failures which precede wha we may call bir h Of a w disease . L 1 . . 4 TH EOBA D SM ITH , M D

In this highly Significant process th e original character O f th e aber nn It rant parasite may be so altered that i ts source ca ot be traced . s course may have beendevious and th e intermediate stages unobserved n t and sinc e o ut so t t t c an no whe hey occurred wiped , ha his course nnn n O f longer be traced back to i ts begi i gs . The appeara ce appar ently ne w diseases associated with ultramicroscopic organi sms is t s n t t n t to particularly mys eriou , si ce our me hods are qui e i adequa e - n t inform us from what direction th e newcomer hailed . The a ces ry t o in t in t in n may be direc ly bef re us , our mids , fac some a imal dis

but to se e it a o f th e o ease, we may fail bec use irreversible pr cess h n u t t n t in n that has brought t e Cha ge abo t . Wi h his co cep mi d we c an n n n n t n t t c u o t also imagi e ma y da gerous combi a io s frus ra ed , t sh r , i n and nt t n n in t t o n t by hyg e e sa i a io , umerous diseases ges a i prema urely t but n o n n tr t n and abor ed , occasio ally e success fully escapi g des uc io n nt th at t n n nt t n n lau ched i o e world , firs u recog ized u il a cer ai mome um n n th nt th n t has bee acquired which bri gs e disease i o e ope .

III .

We are no w in positi o n to V iew th e difficulties to be encountered in discussing th e factors that have led to a gradual decline in th e n mortality due to infectious diseases . This decli e we may readily n t t nt n th t t ti It o t gra t wi hou e eri g e s a is cal field . c mprises all hos e endemic infectious diseases to which th e populationhas become partly n an immu ized d which occur fro m time to time inlimi ted epide mics . Three agencies are cited as claiming more o r less o f a victo ry n in n n t n th e t o n o f n cha ges eco omic co di io s , applica i s medical scie ce, and th e interplay o f natural f o rces still largely unkno wn and no t controlled by human for esight whi ch tend to raise resistance Of th e t and n f h n i hos reduce virule ce o t e parasite . Improveme ts n e c o n n t n o t nt t n omic co di io s provide opp r u i y for a wider , asep ic zo e about n u n n h t n C . O t t n n s i divid als hrough perso al lea li ess n e o her ha d , i du trial changes lead to huge concentrations o f th e population in which th e n t n n nto at n n n t i dividual asep ic zo e is broke i ma y poi ts . O e resul a nt n t n and n a in t n n is co i ua io probable i cre se respira ory i fecti o s . Decrease o f intestinal infec tions has beenaccomplishe d through ade t t n n t n qua e wa er supply a d food i spec io . The sewage problem is still unsolved and all we have done is to convert o ur water courses into Open sewers with occasional expl o sive outbreaks Of intestinal th t t i n disease as e resul . The ime is com g whenth e intimate relation 1 THE DECLI NE OF I NFECTIOUS DISEASES . 5 between water supply and sewage disposal will suddenly develop acute crises inth e sanitary aff airs o f large communities . The widening aseptic zone I have described tends to delay th e passage O f infectious agents from individual to ind ividual . The influence exerte d by various agencies On infection when it has to t n n to n a travel th e longer dis a ce from i dividual i dividu l , as for example whenth e typhoid bacillus comes back by way o f river water ' n w n t be in c o nve e d t receivi g se age , i s ead of g y direc ly , is a problem d ifli c ult to attack because methods for measuring degrees Of virulence must be carried o ut inalien species all of which are naturally insus l f u t n to th e c e p ti b e . The same di fic l y arises whe we wish measure virulence of microorganisms carried by recovered or healthy indivi d l n u n n it t t nas . t o t t The a ral i fere ce, seems me , is ha here is a gradual attenuation going o n which is proportional to th e period since c o n vale sc e nc e and that th e most virulent types are th e ones transmitted h Di h during or immediately at t e e nd of th e acute disease process . p theria bacilli have been found atoxic from throats a variable peri od th t after e acu e proc ess has subsided . Civilization from th e medical aspect may be defined as th e main te nanc e o f anincreasingly dense populati onwith a falling death rate in t n n nt n t . t spi e of free i ercourse Taki g his defi i io as a base , we are safe insaying that without th e steady develo pment of med ical science and t prac ice civilization would have been unable to move forward . In every detail of individual and communal life medical science has formulated protective devices to maintain health largely by th e sup n n pressio Of i fection. Without th e constant application of medical and nt th n t n preve ive safeg uards e huma race coul d no t sus ai itself . I f i t Should drop to th e level O f animals in this respect and throw safeguards to th e winds its fate wo uld be reductionto animal density in population o r even worse unless th e race segregated itsel f into no n- communicating groups and each o ne allowed th e existi ng viruses to u nt u n b r hemselves o t as it were . The um ber o f diseases scattered over th e globe is so great that free interco mmunication o nth e ani mal level might bring so many to be ar o nth e race as to make impossible its t u n t t n t n u n s r ggle agai s o her a ural i j rious age cies . The bringing together o f large numbers of individuals from wi dely f nt n i n th o t t dif ere regio s , as war , is perhaps e m s fer ile method of u t n Old o c nt n n n t n res rrec i g l al diseases , i e sifyi g prevaili g ypes a d even t n n crea i g e w ones . The conditions during war also favor a broader nt t t n t B co ac wi h a imals bo h useful and noxious . reeders of livestoc k 1 6 L . TH EOBA D SM ITH , M D . have learned to separate large flocks whose ancestors were gathered from various regi ons to improve th e breeds into small colonies to th n t t t n escape e u avoidable, almos ca as rophic epidemics amo g large num bers . Medical practi ce performs another function which is ap t to be nt n overlooked by th e laity and no t infrequently a ago ized by i t . I

to th n u t in t t and n t r refer e u iversal c s om priva e , hospi al sa a o ium pract ice to isolate th e sick in such a way as to exterminate in many n t n th n t u n th t n H u n i s a ces e i fec io s age t of e pa ie t . ow m ch is gai ed

t no o ne c ant but n an an by his procedure ell , ma y org ism of superior virulence is Obviously stopped in its course and destroyed and no t only other individuals but possibly large groups protected from epi i n n th e n nt nt dem c i vasio . Where microorga ism repre se s a resista t in tu u and th e n i th th e y pe , as berc losis , chro ic carr ers are e rule, advantages o f isolationand destruction o f th e secretions carrying th e virus consist in a reduction o f th e general level o f infection that to all appearances acco unts for th e large num ber Of allergic individuals n nt n n t n in free from demo strable lesions . This spo a eous vacci a io countries where th e disease has prevailed over long periods is prob n n t h ably a safeguard rather tha a da ger . Wi h t e discharge o f large nu in n t t t n mbers of bacilli Ope ambula ory cases , freely expec ora i g as was th e t t th n o and c o n habi fif y years ago , e da ger of large d sage n n seque t cli ical progressive disease is obvious . It is difficul t from any point O f V iew to establish th e clai m that parasites are beneficial o r evenharmless to th e host. Although para siti sm i s un nt n n n t no nt t t a f dame al phe ome o of li fe, his is argume ha i n t no t to th o . m H is be eficial e h st species Na ure ig res anas such . e is simply an animal and therefore subj ect to laws governing para

o h n siti sm . He is h wever t e o ly species more o r less success fully t u n nat a t in i t s r ggli g to elimi e p rasi ism all s forms from his body . It is probably th e apparent hopelessness of th e eff ort that has led some scientists to state that it might be wiser to cope with infectio us d i s eases in th e animal way by th e elimination o f th e weaker ho sts and th e increased resistance of th e survivors than to try to exterminate th n O f t i i o n e parasites . The defe ders h s v ew have failed to rec g ize th e fact that th e number Of infectious and parasitic agents in e xi s tence have never become widely diff used either among m e n or our

t n lai ss e z - ai r t o n n domes ic a imals . The f e me hod w uld bri g i to play n t t t in n n t ma y hi her o exo ic diseases additio to th e e demic ypes . n t u n t n o an Moreover, eve i f hro gh a ural processes virule ce f y epi

I 8 L . . THEOBA D SM ITH , M D fact th e progress o f medical science to - day depends almost wholly o n

O t t n in th e t n t and animal li fe . T ma erialize his pla s udy Of i fec ious parasitic diseases i t will be necessary to ex ploit all spontaneous animal

to tu th e th e n u in i ts th e diseases , s dy disease Of i divid al all forms ,

ff nth e ul t n th n and ti n e ect o pop a io as a whole, e rise , decli e modifica o s f h and nt a t tu i o t e virus , eve u lly a compara ive s dy Of sim lar diseases t n t t th e i n different species . It will be highly desirable o i ves iga e di seases O f untouched animal po pulations which are closely associ ated t m anin t n t n o ur o wnd o m e sti wi h more or less primi ive co di io s , for t u and n n th e n n o f o ur c ate d species , bo h usef l oxious , are u der i flue ce n f t a t o f n civilizatio which makes research almost as di ficul s tha huma s , ff n n but for very di ere t reaso s . It is obvious that th e research laborato ry must play a large part in n tu t t o f but i t n t its such a a ral his ory s udy disease , must subordi a e analytic tendencies to th e broader V iew of th e whole and assist inth e t It t t n comparative s udy . s resul s will he serve as problems to be n n It n further a alyzed by a more refi ed technique . is eedless to say that this plan m ay be classed as a luxury rather than a necessity in f u h medical research . Those O s who have followed t e development o f research over a considerable period Of years have frequently been faced by th e fact that what we regarded as th e luxury of o ne period n h t n became a ecessity o f t e next. Al hough much has bee done inth e t n n t n n t t and in direc io i dica ed by pio eers , riski g heir heal h lives th e o f un nt n nt th o n wilds civilized co i e s , e w rk perforce has bee frag

n an t n t o n n me tary d desul ory . I thi k tha c mi g ge erations will see established research stations in hitherto only partially explored te r ri to ri e s where living conditions will be created to make research no t n but m n t to n and o ly possible, re u era ive medical scie ce , where all O f a in t f forms dise se various species will be obj ec s o research . THE HEART

ECO NOMI C AS PECTS OF HEART DI S EAS E .

BY H V E . A EN EM RSON , M D .

Ne w Y rk o .

No small part o f th e present colossal wealth o f o ur country is due to th e accumulated saving of th e lives of m e nand womeninth e years o f t t t u t t th e in th e t t their grea es ma erial prod c ivi y , by fall dea h ra e n It n t t inth nt and from pulmo ary tuberculosis . is u likely ha is cou ry i no ur time any other Change inth e prevalence of disease c anprod uce such impressive increase in th e earnings and savings o f our people . t t i t th e n t Now hat tuberculosis has los s leadership Of colum Of dea hs , and t t h e inth e t t hear diseases have emerged , par ly by t fall dea h ra es

t and rt th e t and t n from o her causes , pa ly because of grea sus ai ed increase inth e death rates from heart disorders as th e most frequent

th e t l nt t of causes of dea h , popu ar i eres , as well as medical , drives us to analyze causes and costs inthis field of pathology as a comm unity problem . In 1 92 1 it was esti mated that th e per capita cost o f tuberculosis to th O f th e nt t t was nnu and t t t e people U i ed S a es a ally, ha his n t t n t n t an ti n burde , i f dis ribu ed amo g hose perso s wi h ac ve, cli ically n t nt to nn ti nt recog izable uberculosis , amou ed a ually per pa e , and that th e total loss d ue to tuberculosis during th e entire life span o f th e population at th e then rate of tuberculosis mortality would amount to No better confirmation O f th e adage The first wealth is health is to be found than th e estimate of economists that th e value of human lives in this country is at least five ti mes that O f all material possessiona'l' While th e implications of th e title O f this paper may be as broad th e n u an t t i t n t nt as ra ge of h m ac ivi ies , will be u ders ood for prese “ t t n t n i s th o n purposes ha eco omics , or poli ical eco omy e s cial scie ce which treats O f that portion O f hum an activity which is concerned

* . f fo r u Emerson , H A Brie Investment in Adeq ate Prevention o f Tube r i lo s s . c u Am . Of Tub . N . O . 6 Au . 1 22 Rev , Vol . VI , , g , 9 . “ n u . . u O f M rO f . e Co . 1 t . . . u . D bli , L I Val e a Man p Li e Ins Stat B ll , Vol . VII , 6 8 an . un Au . 1 Nos , , J e d g , 926. 2 0 HAVEN EM ERSO N , M . D .

t nn n and t t n th t r wi h ear i g a livi g, ha u der e erm heart disease a e included those various conditions provided for under th e four titles th e nt n t n t o f t 8 - 0 di ti of I er a io al Lis Causes of Dea h , 7 9 , Pericar s , En and t ut n n t and Ot do Myocardi is (ac e) , A gi a Pec oris her Diseases h a t of t e He r . n t to th e t t n t We are ecessarily limi ed use of hese few erms , i adequa e t t t n n no t t as hey are, because wi h rare excep io s u der o hers are he re to be found records of th e distributi onand durationo f heart diseases which permit us to estimate th e character and th e extent o f th e influ ence O f this particular group o f di sabilities uponearning capacity and span o f life . The bearing o f disease upon th e earning of a livelihood depends

t t nth e n n a On t th and t n a leas upo age of a i dividual t se , e degree dura io O f t th e and th t n to t disabili y as process develops , e ex e t which dea h t n from his cause shorte s li fe .

n t n t to t th e o f t I forma io is herefore be sough from records dea hs , and O f n t tt t n ti t ti n Sick ess , where hese la er are assembled hrough i s u o s o r n u t n ti n n o i ti n age cies s ch as hospi als , dispe saries , visi g urse ass c a o s ,

n t and n n r n t n f i dus rial i sura ce o compe sa io O fices . While no economist o r statistici an c an expres s infigures alone th e ’ O f n th t u t t t a t n in value ma s li fe , ere is a r s wor hy me hod Of c lcula i g t nn th e t t n o n th n t nt o f erms of ear i gs , rela ive re ur s e i ves me life n ff n whendeath comes to m a at di ere t ages . "" The studies O f Dublin and Lotka will be used as th e basis O f estimating th e economic losses due to heart disease in this paper . By these authors th e mo ney value of a life at a given age is do n ’ sid e re d to be th e diff erence between th e persons calculated future

nn at th e t t and th nt t Of ear i gs ime of his dea h , e prese wor h his prob n t able future expe di ures . Since th e o verwhelm ing maj ority o f m e n in th e United S tates to — un in at t n th e n o f day are fo d , or leas earer i come class

nn t ninth e o r n n o ur ear i gs ha a year class over , we shall co fi e estimates to th e former without attempting to make allowance for that relatively very small proportion O f heart patients and death s n f n n inth e n . F n n o occurri g higher i come group or co ve ie ce refere ce,

th e o n t t th tu o f u n however, foll wi g abbrevia ed able from e s dies D bli and Lotka will indicate th e relative values of thes e two groups O f n ear ers expressed indollars o f value at th e age o f death .

t 1 26 . n . M f In . t. u . un an Au . u e t. e s e d D bli , L . I Li Co . S a B ll , J g , 9

2 2 M D HAVEN EM ERSO N , . .

h R n It e nt t t in and As t e egistrar Ge eral remarks , is evid ha early a a t a t as n to ci middle life t le s , he r disease a whole is fou d be espe ally th and t no e tan fatal to e poorer classes , al hough record has be n ob i ed n n o f t t t m t i t to o f th e social i cide ce mor ali y from acu e rheu a ism , is be pres um ed that even i f all classes were equally subj ectable to this disease i ts eff ects uponth e valves o f th e heart would be more serious ” i n n r ti n to those least a positio to take th e necessa y precau o s . Whenth e mortality fro m valvular disease o f th e heart is distributed by specific occupations th e death rates from this condition are found n h to vary widely accordi g to t e Character o f employment . I f we consider th e death rate from valvular heart disease o f all Occupied and retired males ( 2 0-65 years ) as we find th e low mo rtality rates among

Insurance o fli c ials 2 30 249 Bank O ffi cials 334 Anglicancle rgy 391 Millers 393 Medical practitione rs 438 Roman Cath olic prie sts 472

Those occupations with a high ratio o f mortal ity fro m th is cause are

Cotton Carde rs 2 1 70 Cotton stripper s and g rinde rs 2063 Barmen 2024 Slate masons 1 994 File cutters 1 852 Cutlery grinders 1 72 7 Slate rs and tile rs 1 727 Co tton blo wro o m operatives 1 688 1 666 Slate miners 1 647

Similarly th e occupations showing particul arly high mo rtality rates “ ” from O ther Heart Disease ( chiefly myocardial ) include many lo w and nt u paid disadva ageo s employments .

Tinand co ppe r miners b e low g round Cutlery g rinders Slate masons Barristers Hat f ormers and p lanke rs Tin and copper miners C n and n hi a, kiln ovenme

z s e tc . Pottery dippers , g la er , Cellarme n Cottoncarder s 2 ECONOM IC ASPECTS OF HEART DISEASE . 3

From th e less ample and conclusive evidence in this country we ’ * find as given in P e d le y s tables of proporti onate mortality from n n t n i t 1 2 princi pal diseases amo g te occupa io s n New York Ci y, 9 4, t t i and t t that bu chers , ailors , c gar makers , shoemakers have dea h ra es from heart diseases considerably higher than th e rate for al l th e i n t t n t . F t t occupa io s lis ed as a group ur hermore , is see from his same study that in 1 92 0 th e proportionate mortality for occupied inth e nt t t te n and t males U i ed S a es , years over , was higher from hear n n th t ix n diseases tha for a y of e o her s leadi g causes o f death . The duration of heart disease as determ ined by various sickness t F n and u n 1 1 - 1 in t surveys , repor ed by ra kel D bli ( 9 5 7) Nor h Caro ” n nn n and Massac h use tts ' li a , Pe sylva ia , New York j differs radically h t n n t n from t e dura io Of all sick esses aken as a group . Calculatio s n t th n n based o these surveys jus ify e followi g stateme ts .

One quarter Of all sickne sses lasting les s than two we e ks ; 3 770 o f all r e n t ntwo e s hea t diseas lasti g less ha we k . o f all sicknesse s lasting less than th re e month s ; o f heart e e as n s th n t e m t s dis as l ti g les a hr e on h . 70% O f all sickne sses lasting less thano ne yaar ; o f heart di sease in t no n e last g less ha e y ar. o f all sickne sse s lasting th re e years and ove r ; o f heart d s n t e e e s and e i ease lasti g hr y ar ov r.

Among New York state factory workers in O f total s t o n nt o f t ae o r t wage were los accou hear dise s s , los per case ,

t o n nt t o r t e r while were los accou of uberculosis , los p a c se . Sickness from organic heart disease among Office employees in a large commercial o ffic e § in New York City caused a loss of worki ng days per annum per persons e mployed and showed a loss O f days per case of illness which constituted o f all n t th e di n t n worki g days los , ffere ces be wee male and female workers n no n n bei g of sig ifica ce . There were lost o n account o f heart dis n n eases cale dar days for each perso s employed, o r

n e . n e Of u . t t in h t nd . , e . o ur . I H dley ra Tr d cc li y U . S . P F k G O p Mor a , J y g , IX 1 1 . . . 1 2 Vol , No , Nov , 9 7 . Du lin b . n . I e L n e e . e t , L , Fra k l, K Sick ss surveys unde r M e tropolitan Life Ins 1 o . 1 6 1 . C , 9 and 1 9 7 . a r S e . k i . . y , . e 1 H D Sic ness Among N Y Stat Factory Workers in 91 9.

. . te t. o f o e . u . . 1 00 Au 2 N Y Sta D ep Lab r Sp c B ll , No , g ., 19 1 . un t o n Personal Comm ica i . 2 M D 4 HAVEN EM ERSO N , . .

n o f t n cale dar days per case hear disease , or of all cale dar days o n n n a n lost accou t of sick ess mo g these employees . There were cases o f heart disease per persons employed in 1 92 5 amounting to cases per clerk years or o f all cases O f d isability u n f o r that year . ( Fig res from Personal Commu ication in Analysis o f health insurance claims o n account of heart diseases*

t t t n n to th e a e Shows ha days are los per claim , varyi g accordi g g o f th e claimant from 42 days among those 2 5-2 9 years of age to 1 2 3 and 1 50 days among those 50 - 54 and 55-60 years o f age t respec ively . ’ ' In B rund ag e s study o f Sickness Amo ng Industrial Em p lo y e e sf he found that according to th e length o f th e maximum disability th nu f t period provided for, e mber of days o disabili y per case varied

6 to 1 2 2 t th e t no f t from 5 days , as compared wi h dura io disabili y per 8 to 1 6 1 in t case Of 4 days uberculosis . In th e same report th e average annual number O f cases o f heart disease as a cause o f sickness disability per male industri al workers ( 1 92 2 - 2 4 ) was found to vary from inth e public utilities n n n to th a d t a d in t n tr . amo g e iron s eel workers , o her i dus ies ’ In Dublins study of Causes Of Death by O c c up ati o ni: from th e n n n t t n t Metropolitan Li fe I sura ce Compa y mor ali y experie ce, dea hs from organic heart disease constituted 1 2 % O f deaths fro m all causes varying from among railway enginemen and trainmen to among farmers and farm laborers and for females rangi ng from among bookkeepers and Office assistants to ff n ar t amo ng housewives and housekeepers . These di ere ces e doub less d ue inlarge measure to th e small number Of cases dealt with as n n well as to th e age groups o f th e perso s i volved . ’ A further analysis of Dublins study reveals for all occupations th e percentages o f all deaths represented by those due to heart dis

n to th e se x and o f th e as eases , accordi g decade li fe of dece ed as follows

Ag e Group s. 1 5 -2 4 2 5 -34 3 5 -44 4 5 -54 95 -64 65 and o ve r

MManu ed f u u nd at t ss c s . e o a , R J . Proc ing s Cas alty, Act arial, St is ical A o - - c iatio no f m e c 1 1 20 1 1 6. A ri a, 9 9 , pp . 77 9 ‘ ‘ n s 1 26 2 2 t t u e t e t . . l U i ed S ates P blic H al h R por , 9 , Jan

B ll NO 2 t . 1 1 u 0 t . i . . 7, U . S . Labor S atis ics , Mar , 9 7

'

2 6 . HAVEN EM ERSO N , M D .

There were only deaths from heart diseases in persons under forty years o f age .

Under 1 0 years o f ag e 1 0-1 9 2 0-2 9

0 - in th t n at The decade 7 79 years , which e larges umber O f de hs th e t o ne u n t t t t t occurred , is las for which D bli es ima es ha here is any balance o f money val ue in favor o f th e individual between hi s n n t probable ear ings and expe di ures . The largest number o f deaths from nephritis and from cerebral in th e o f 0- i th e t hemorrhage al so occur decade life 7 79, wh le larges number of deaths from cancer o ccur in th e decade 60 -69 and o f 2 -2 tuberculosis inth e decade 0 9. No t alone th e total number o f deaths from a particular disease but their distribution among th e decades o f li fe and th e duration o f th e disease as a cause o f relati ve o r complete disability are th e deter m ining factors o i its economic cost to th e indi vidual and the nt commu i y . In n t t n t nand t deali g wi h hear disease we must co sider dura io dea h , o n th e th t o n nt t moreover, basis of e hree d mi a e iologic groups , rheu n t ti a d t o t o r n nt . ma ic, syphili c ar eri sclero ic se esce In translating clinical histories into graphic form for th e purpose o f expressing th e spread of di sability and death across th e years o f th e w n t o f th e t nti n life, we have follo i g pic ures hree groups me o ed . ( Chart Course o f Heart Whenrheumatism completes i ts cycle from o nset through aperiod o f disabling symptoms to and through th e time o f decompensationto t n th e 0 u in h dea h , all u der age of 4 , which occ rs t e great maj ority o f find t t th e n t un 1 0 O f in 1 o f cases , we ha o se is der years age 970 th e t e n 1 0 and 2 0 o f in n2 cases , be we years age be twee 0 and 30

“ In this chart will be f ound g raphically expre ssed th e life hi story O f th e ave rag e heart patients o f e ach o f th e thre e chief c ate g ori e s O f hea rt dise ase ” th e n o f f um m z f m th across spa li e, as s ari ed ro e lite rature by Cohn ? i Co hn f E . e e se f h w , Al red H art dis a rom t e Point o f Vie o f th e Public A - - e m . e t u . n . . a d 2 01 86 Fe b H alth ; H ar Jo r , Vol II, Nos 3 4, pp . 75 3 , 3 407, . and

Apr . , ECONOM IC ASPECTS OF HEART DISEASE .

« . 0 0 5 0 3 0 5 0 0 0 0 0 0 0 8 0 8 0 0 8 5 0 2 0 0 8 0 0 0 0 3 0 0 5 0 9 5 3 0 m 8 3 5 0 0 2 0 8 0 0 ” 3 8 0 0 m 3 0 0 0 3 a 0 m 8 5 0 0 2 5 0 0 0 0 — 0 3 0 0 0 Em : 5 0 3 0 0 0 0 0 0 9 0 8 0 8 5 0 0 8 0 0 0 9 0 0 0 8 8 8 5 0 0 0 0 3 o 0 0 h 0 5 0 0 0 0 0 m 0 0 0 0 0 c A 0 0 0 0 z 0 0 0 n m 5 9 m 3 8 8 0 5 3 8 0 fl > 0 3 m 0 v 0 0 0 8 0 0 0 m > 5 8 5 8. 0 8. 5 0 0 3 0 3 0 0 , 0 0 8 0 0 5 . ? 0 A 5 5 8 . E5 0 3 0 5 0 2 0 0 5 5 0 0 0 8 5 5 0 0 0 0 0 1 0 0 0 5 0 0 5 8 0 5 5 0 0 0 5 8 8 0 0 . 0 0 0 0 5 0 0 0 5 ” 0 0 5 0 1 8 0 0 m 0 0 0 5 0 £ 5 0 9 9 0 5 m 8 8

5 0 0 n 0 0 0 o 0 8 0 3 0 0 . 5 » 8 0 5 0 8 m 0 0 m 8 0 0 0 3 0 o 0 0 0 8 0 0 3 0 0 0 0 3 3 7 0 0 0 8 8 3 0 2 0 9 5 5 5 9 H 8 0 8 , 0 0 « 5 0 0 m 0 0 0 0 0 a 8 0 0 5 0 8 0 5 fi 0 E0 0 a n 5 0 0 0 8 0 0 A o 0 0 0 0 2 0 c 0 0 “ 8 m 8 0 0 5 E 0 0 0 0 m 0 0 0 0 3 u 0 8 0 ". 0 2 5 0 0 0 0 m 8 8 0 8 5 u 0 c i 0 0 u 0 5 0 0 0 m 2 0 b 0 8 : 0 u 0 8 m 0 0 0 w M 0 0 5 0 o 5 S w 8 0 0 8 8 0 0 n 0 0 8 t 0 0 8 0 0 3 o 0 m 3 : 5 w _ 0 8 0 0 0 m 0 n 0 9 0 0 m 0 0 5 o 0 o 0 5 2 3 0 0 0 : m 0 8 0 0 : 5 0 o 0 0 0 : 0 0 0 0 0 3 8 m 5 0 0 0 a 5 5 8 0 8 0 m $ 0 8 0 a 2 0 5 0 8 0 8 5 w 0 0 0 o 8 0 6 0 0 z 0 0 0 0 0 0 0 o 0 0 § 5 3 0 0 h 5 5 8 h 0 8 0 0 9 5 8 > 5 "0 2 8 HAVEN EM ERSO N , M . D .

0 0 2 1 . in and between 3 and 4 in % of the cases Furthermore , and we find on the average, a duration of four years between onset o partially disabling symptoms , which thereafter continue ab ut 7

o o o t years bef re dec mpensation , and with it pr bably complete disabili y r o develops , which continues , alternating with pa tial and occasi nal

fo r o . w rking ability , four years until death 1 8 0 With syphilis , the infection which occurs between and 3 years o f so r c o n age is followed , far as heart disease including ao titis is 1 0 2 o o r cerned , by from to 5 years without sympt ms conscious dis o two ability , death f llowing usually within years after the development o f disabling sympto ms . The deaths from syphilitic heart disease are

o 80 o f o f theref re to be found in % the cases after the age forty , in 1 2 o o 60 o f % in pers ns ver , and in about 34 70 the cases each in the

- - decades 40 49 and 50 59. O f the 2 0 % o f syphilitic cardiac deaths occurring under 40 years f o 0 0 . age , three out of four are in the decade between 3 and 4 years to In the great mass of all deaths attributed diseases of the heart ,

o o f 0 o f o th se the senescent type , constituting 9 % the t tal , the onset * o f symptoms occurs ( according to Wycko ff ) by decades as follows

This type o f heart disease is not acco mpanied by any mo re or o ther disability than is commonly found amo ng all pers o ns in the later

o f t e decades life, the subj ective symptoms of h disease rarely causing the patient serious occupational handicap unless he be alarmed by what he is to ld abo ut his sickness .

In most cases in the senescent type of the disease, cardiac failure o f c a disabling degree o curs , if at all , so near to the time of death and at so late an age that a calculable peri o d o f economic disability

o does not devel p . Practically all deaths attributed to the senescent type o f heart dis

* k a c B .o u o m in fic o n W c o fl o h . y , J n S t tisti al Studies earing Pr ble s Classi ati l n m . a o r Vo I f . o f . o o O c s . A . Heart Diseases II Eti l gy o rga i Disea e He rt J u , , 2 No . 4, Apr . , 1 9 6.

0 . . 3 HAVEN EM ERSO N , M D

th 2 8 De a Co s ts 1 . , 9

o f I st The po pulation of the United States is estimated as July , 1 2 8 r 9 , to be a little over The death rate from hea t diseases ( 87-90 ) in the Registration Area in 1 92 5 was per

o f the population . It is estimated that the deaths from

1 2 8 o f 1 2 no t be heart diseases in 9 , i f the rate 9 5 is exceeded , will When distributed by age groups accordi ng to the d i stribu tion in per cent of heart deaths in 1 92 5 and charging for the numbers o f - o f occurring at each decade , the value a li fe at the mid period the o to be 1 decade , we find the loss in terms of m ney value $ , 5 f o r per capita o the population .

Esti m ate d Di st rib uti on o f D e ath s Li fe Value at f r m e ar i s e as e 1 2 8 Mid - e ri d A e o H t D , 9 p o g

70-74 766 75 and o ver

While it may be quite justified fro m a purely financial point o f view to calculate the l o s s to the c omm unity of the li fe of a woman on the basis o f fi fty per cent less monetary value than that of a m an o d a o o o o f at the same age , there is a g o re s n to c nsider that the l ss life

o e m o fo r fr m heart dis ases a ong w men , decade by decade, and equal

o i numbers , constitutes quite as heavy a financial loss t the fam ly and ’ ho me in terms o f dollars wo rth of service and care as results from the same cause in the male . This is particu larly the case in the e c o o o f r i e o u i . . nomic gr up we are using as the basis est mates , , persons n . o earning a year or less Therefore, attempt will be made to propo rtion the t o tal cost o f heart disease sickness and de aths o e x acc rding to s incidence . The death rate from heart disease in the reg istration area having o 1 2 0-2 1 1 8 increased fr m 9 5 ( 3 % among males , % among females ) it is certain that the 1 92 8 estimate of deaths from the cause r is conse vative and well within the truth . 1 ECONOM IC ASPECTS OF H EART DISEASE . 3

Ho s i tal Co fs p s .

1 2 n 66 In 9 7 in the general hospitals in the U ited States , 70 f 6 o n o o o the 345 3 4 beds were used the average thr ugh ut the year, * r 1 2 1 o C o It was found in 9 in New Y rk ity , that while

f o r o f all general hospital patients are admitted heart disease, of the days of care provided in these hospitals are fo r this clas s

o f o r o f o f patients , a total days care for heart patients in

o o f the United State s or , at an average c st a day per patient , a cost o f The average co st o f ho spital care in public general hospitals in New York State has in recent years ( 1 92 6) be en o r so - per patient day , and in private called endowed general

hospitals per patient day . The experience of the S tate o f New Yo rk including the City of New York shows a much smaller pro portion of all h o spital patients

i e o f o . . o t be heart patients , in the general h spitals the State and City as compared with in general ho spitals in the city

o taken separately . I f then the of all general h spital patients i n C a New York S tate and ity are heart patients , and we have le rned ( 1 92 6) that the heart patient on the average uses about tim es o f o i d o as many days hospital care as ther pat ents , we shall find when applying this situatio n to the hospitals of the co untry as a whole that there wo uld be o f total bed days o f h o spital use d o to o f o r ev ted care heart patients , days x X

o o o f o 1 X which at f ur d llars a day care w uld be $ 5 , The actual cost of hospital care fo r heart pati ents for the United States as a whole pro bably falls between these two figures ;

i no o o . e . t o . , ver thirty nor under fifteen milli n d llars a year The reader familiar with the social prac tise of diff erent parts o f t ff o f the United S ates as it a ects the supply, use and per diem cost ho spital bed care for heart and o ther general medical patients will realiz e that esti mates based on the experience in New York City

r o and State may be in e ror, but inf rmation on the points at issue o o o are no t available from o ther large p pulati n gr ups . Also the fact that the reported death rate from heart diseas es for New York State m f is higher than for any other. state ay result in an extent o hospi

’

n . o m o n . Th e h o c h E ers , Haven C r i Disabled Heart Patient Nati n s Healt , n 1 2 Ju e , 9 3 . l f Hase o . o o f o m m to m o T y , R bt . H Rep rt C ittee ake a study Heart Disease

in h e S o f o to So c . 1 1 28. t tate New Y rk State Med . May , 9 z 3 HAVEN EM ERSO N , M . D . tali z ati o no f this gro up o f diseases above the average for the country o t as a who le . When more c mple e information is available the esti

ff to vi mates o ered here and now will have be re sed , but i f present o and o o trends in death rates and h spital use c sts c ntinue , the revision is likely to be upward rather than down . th e o f It was found , furthermore , that of total cost operating

l o the public general hospita s in New Y rk S tate , including New York

C 1 2 6 f o r o f ity , in 9 went the care heart patients , and of the o c st in the private general hospitals went for this purpose, the latter not being provided so c o mmonly with beds available for the more chro nic f o rms of disease . I n the private hospitals in New York City the com parable figure was

u n N rsi g Vi si t Co s ts .

Appro ximately persons are in the boro ughs of Manh at

R o o f C tan , Bronx , and ichm nd New York ity , within the reach m o f the V isiting Nurse Service ( the Henry Street Nurses ) . A ong these people nursing visits were made to patients discharg ed

o 1 2 o f w . fr m care in 9 7, hich or were for heart patients

o ff Stated in an ther way , these nurses visited di erent patients

6 2 o r in the year, of whom 9 , were heart patients , who received an average of nursing visits each .

o o Am ng the entire population of the United States , appr ximately

o i z o f f rty t mes the si e the community served by these visiting nurses , either visiting nurses or other pers o ns with les s skill and at more o r o expense directly indirectly , will be f und to be providing some

o f o o r o se m c e s degree h me nursing, a t tal of individual , which at the present actual average cost of visiting nurse service o f a visit wo uld be be

Co s t o Clini c al Care f .

The six millio n peo ple of New York City appear to be adequately served by the several heart clinics , as far as heart patients , suitable o n c o o fo r e on mic and pathol gical basis ambulatory clinic care, are l concerned . Almost all ambu atory heart patients not under the care o f private physicians go direct o r by reference fro m other out-patient o r dispensary classes to the special heart clinics scattered throughout the city .

3 4 HAVEN EM ERSON , M . D .

o o patients thr ughout the United States in a year , and ab ut half as many i f we base our calculations upon use Of beds for heart patients

o o f in h spitals thr ughout the state outside o New York City . In 1 92 3 it was found * that in large g eneral hospitals o f New York City the average leng th Of stay o f heart patients was days for o f 2 0 each such patient admitted , the leng th stay varying from days at Bellevue Hospital to 1 40 days at the City Hospital fo r chro ni c invalids . It was f o und in 1 92 71‘ t hat the average lengt h o f stay o f heart patients in 1 0 1 general hospitals in the State o f New Yo rk was 2 4

r o Co E days , va ying fr m days in Westchester unty to in rie C o Co o c o nse rv ounty , New Y rk unty giving Taking the m re ative and pro bably more representative figure of 2 4 days care per c an o n o patient , we estimate that basis , that there were s mewhere between and heart patients admitted to general ho spitals according to o ur use of state o r city figures for the number i o f beds occupied by heart pat ents in general hospitals . It has been found in various surveys of ho spital and dispensary practice and from studies o f the needs of patients as discharged from h o sp itals i that among general medical and surg ical patients and maternity patients about 1 0 % needed as much as three weeks co nvalescent care . More nearly twice as many o f hospital heart patients require such a co nvalescent period as d o the general run o f f r ix o f o s o . patients , and a weeks peri d instead three weeks

o f Similarly , it is found that , while general dispensary patients

e fo r some two p r cent need convalescent care three weeks , probably at least 4% o f heart patients attending clinics need such care for as ix much as s Weeks . Twenty per cent o f hospital heart patients would be somewhere between and according to our basi s o f estim ating heart patients as above . Four per cent o f the probable o ne - f o urth o f the ambulatory heart pati ents attending clinics as given abo ve) would be

m o n and Wo u h te r . . h o nc e e r n E ers , Haven, g , M L C r i Disabl d H a t Patie t, ’

l NO 6. o h n 1 2 V o . Nati n s Healt , Ju e , 9 3 , . V, l o r . o o f o mm e e to m e S u o f e r Halsey, R be t H Rep rt C itt ak a t dy H a t

th e o f Ne w o to . So c . 2 1 1 28 Disease in State Y rk State Med May , 9 .

‘ Cle ve land Ho s ital h S 1920 o c c i p and Healt urvey, , C nvales ent Care, Frederi B h rus , M . D . , p . 939. ECONOM IC ASPECTS OF H EART DISEASE . 3 5

Six weeks co nvalescent care for these two g roups of patients would amount to somewhere between and days o f convalescent care . This type o f care co sts about half as much per diem as does general

so hospital care, the expense of such care if provided would be between and We do no t know the number of days o f care provided f o r heart

o o o r Co nvale s patients in c nvalescent h mes , but we do kn w ( B yant ,

-2 to 1 2 . 2 cence, 9 7, pp 55 57) that there are about beds devoted convalescent care fo r part or all of the year outside of the vicinity o f Ne w Yo rk City and abo ut mo re in the New York City M environs . any of these beds are available for only a few months O o u o th a . e each summer thers , though intended for use thr gh ut ye r, o e are not always ccupied , and there is no reliable r cord of the number

f C o o bed days of onvalescent care pr vided for heart patients . C ’ However , since New York ity s people are pretty well served in respect to convalescent care fo r heart patients by the 370 beds in use f o r this purpose througho ut the year and used to a high percentage of their capacity , we might expect twenty times as many beds to be needed for the country as a whole or which falls b o f between the figures given a ove, days care calling for

beds and days requiring beds . Our estimates o f i cost are then with n reasonable limits .

‘ It is fully reco gnized that no such amount of care for convalescent heart patients is at present provided fo r in insti tuti o ns operated for this purpose . However , i f heart patients do not have such care in o r o institutions its equivalent under individual conditi ns , they will ff f a o . su er avoidable d mage from lack it Therefore, this item is added to the total estimate as a proper ch arg e .

h ro ni c i c k Co s t C S s . .

o f c * In a survey chronic si kness; recently completed in Boston , it was found that o ne person am ong every 1 85 of the population was a chronic invalid and that of these were heart patients , of

' whom were persons under twe nty y e ars o f ag e and 0 0 were persons under 4 years of age . All but 3 70 o f all chronic heart

* h o nc o f B o o 1928 Am m o nc o f C r i Disease Survey st n, , by y Ha burger , C u il o c nc B o o n S ial Age ies , st . 6 . 3 HAVEN EM ERSON , M D .

o to ne o was patients were f und ed care through ut the year , and it further f o und that this was generally provided at about o ne -hal f the cost per patient day of the co st of care in general ho spitals . O o n this basis applied to the United States as a wh le, the estimated chro nic heart patients needing care the year round are prob

o f . 1 2 0 ably co sti ng in the neighb rhoo d o a year ( , 1 85 X X 70 % x 365 X

Assembling our variously estimated items o f th e cost of the medical and nursing care of heart patients in the United States in this year , we have in round numbers for th ose

A Under c are in general h o spitals to B Under c are by nursing visits inh o m es ’ C Attending c linic s o r ph ysi c ians o ffic es D Under c are in c o nvales c enc e to E Under care in c hr o ni c stage

To tal c o st f o r a year to

Or we might properly say that we have estimated the above costs o n the basis o f a total o f to heart patients o f the various categories in a current gi ven year o r j ust under one per cent o f the population as follows :

A Under c are ingeneral h o sp itals to B Under c are by nursing visits in h o m es ’ C Attending c linic s o r ph ysic ians o ffic es D Under c are in c o nvales c enc e to E Under c are in c h ro nic stage

to

Estimates have ranged fro m one to two per cent o f the po pulatio n as constituting the total of heart patients . Using one per cent o f the population as being nearer o ur o wn i est mate, built up from the various groups probably receiving care, and using the l o wer of o ur total co st fig ures we find that the average heart pati ent in the United States to-day probably carries an annual charge o f or we might properly say that heart disease puts a burden of about 75 cents on each person o f the entire population each year . The cost o f heart disease deaths occurri ng in the various decades o f to 1 o r o f li fe was found be $ , each year, a loss for each member of the population .

8 3 HAVEN EM ERSO N , M . D .

Probably s o me postponement in the ag e o f death from heart di sease o f rheumatic origi n and p o ssibly some reduction in the incidence o f i acute rheumatic fever might result from an expenditure per pat ent,

r o f o per capita population , for heart disease more nearly equal to the sums found desirable for th e prevention of tuberculosis and the treat ment of the tuberculosis patient . o f The burden heart disease falls more heavily , absolutely in terms

f o f o o incidence and deaths , and relatively in terms l ss of livelihood , d - u - upon the unskille wage earner, the nder privileged man and woman , f m than upon any of the h igher earning or social levels o the co munity . o f o o f Because its duration, heart disease, with the excepti n tuber c ulo si s a o f c o n , ment l alienation and certain forms chronic arthritis , stitute s b d o s heavier urdens upon wag e earners than other disea es , this burden increasing with each decade o f life from twenty-five to -fi Sixty ve .

NOTE: Grateful ac kno wled gm ent is h ere m ade f o r th e valuable mate rial c o lle c ted and prepared fo r use in th is p aper by Miss Jes sam ine Wh itney and r f f f Miss Beat i c e A . Mye rs o th e staf o th e Am eric an Heart Ass o c iatio n and

‘ by Miss Claire Lingg o f th e staff o f th e Heart Co mm ittee o f th e Ne w Yo rk Tu c o and e h o c o ber ul sis H alt Ass iati n. THE HEART I N I NFECTION .

H . BY OMER F . SWIFT , M D .

ke f e i u e f o r e d ic a e s e arc h Fr om th e Hosp ital o f th e Ro c lle r Ins t t t M l R , n e Ne Y rk th r e e a d v ue w . 66 St t A n A , o

The subj ect assigned for this paper rec ogni z es that heart disease is

ff o o f o f rarely an a ecti n the heart exclusively, but rather only a part

o t o o a general systemi c malady . In b h its anat my and physi logy the

a c o to o o heart has unique fe tures whi h require c nsideration , but cl se attention to them without due regard to th e general problems of the biolo gy of infection and degenerati o n may have a deterring rather ff than a beneficial e ect . It has beco m e customary to divi de heart diseases roughly into two general types : infecti o u s and degenerati ve . The first are thought to exert their baneful influence largely during the first four decade s i o f . V li fe, and the second class during the remainder ital stat stics ,

c o m o o f indeed , nfirm this i pressi n ; and a study the form and functi o n o f ti ssues during the afternoo n of li fe leaves little doubt of the im po rt ance of the alteratio ns norm ally occurring in senescence as playing an impo rtant rOle in the pro duc ti o n of cardiac diseases . But the age- linked features of these later alterati ons in structu re may have blinded us somewhat to the relati o nship between infection and

o degeneratio n . Indeed some recogniti n of this relationship has bee n

o o c i o o f r o gained fr m the c nstru t n actua y statistics , where their pr per

m o l th e ' tud evaluati o n is a atter of dollars and cents . But n y as S y o f patholo gy beco mes m o re and mo re a correlation o f distant as well e ff r i o o f as imm diate cause and e ect , will the e emerge a recognit n the true relati onship of infection during the early years o f li fe to late degenerations . The eff ect of any infect ion upon the heart depends upon at least two factors : the natu re of » the infection and the reactio n of the to t o . heart hat particular infecti n The heart , being a complex organ , in turn Shows di ff erent effect s ac cording as o ne or ano ther o f its

o . ff o component parts is inv lved The heart , moreover, su ers a d uble insult bo th as a direct result of bacterial injury and as an indirect result of disturbe d circulation ; hence a vicious circle is quickly

. o established in a cardiac infection We must , theref re, keep these o m complicating fact rs in ind , for the result o f even the simplest 0 4 H OM ER F . SWIFT , M . D . inj ury from bacteria is much more complicated than we imagi ne o when we reduce the vari us elements to Simple terms .

a z Ag in, we must recog ni e our comparative ignorance as to how Fo r a . d o the myoc rdium reacts to , noxious agents example, we not kno w to what extent or in what direction edema pe r s e influences th e various functions o f the heart muscle : Does it increase o r decrease o r i i ? D o ne irritability, contractility , conduct v ty oes it increase and decrease another ? What is the synergi c o r antagonistic result o f these factors ? Does mild prolong ed irritation from infection lead o r fo r to hypertrophy, is hypertrophy only a response to a demand increased work ? Until we are able to gi ve a positive answer to a o ur o f m ny such questions discussions will , necessarily , have much a hypothetical character . to We are in possession of enough data , however, sketch at least rough outlines o f many features o f infectious heart diseases . At times it is necessary to o btain informatio n concerning some factors from a direct study o f infectious agents in parts o f the body permit

m o ting direct exa inati n , hence more accurate analysis . We must also resort to information gained from experimentation on lower animals , though in this respect, it must be confessed, we have

so o f obtained relatively little direct knowledge , in far as infection the heart is concerned . Aside from the type o f heart invo lvement o o f we f und in diphtheria and that subacute bacterial endocarditis , are unable to repro duce with any deg ree of regularity in lower animals the various pictures of cardiac infection that we encounter na t . Co in man mparative experime t l inves igations , therefore , have yielded more direct informati o n from the standpoint o f physiology than from that o f infection .

o o f o ur Keeping reservati ns this nature in mind , we shall base

“ o o f discussi n upon typ es reaction in certain infections , rather than attempt to cover all o f the featu res o f infecti ous heart disease . A satisfactory picture o f the various f o rms o f cardiac inj ury from bacteria can probably be most clearly presented by using as examples : the following diseases diphtheria , scarlet fever, rheumatic fever,

o . subacute bacterial end carditis , syphilis and septicopyemia

t e r Diph h ia.

In diphtheria the simplest picture o f cardiac inj ury is seen . The

i o o o o heart s p is ned by the t xin pr duced at a distance, for it has been

2 4 H OM ER F . SWIFT , M . D .

ner to drug s . The ultimate outcome in any g iven case doubtless depends upon the rati o o f uninj ured to injured muscle ; and the

o e t difficulty enc untered at the b dside is o estimate this ratio , for upon

o it rests both treatment and pr gnosis .

arle t e ve r S c F .

f c o m The dif erent cardiac complications of scarlet fever, althoug h t para ively infrequent, illustrate the various forms of cardiac inj ury resulting fro m infection more clearly than does any o ther single disease . For purposes o f discussion these complications may be I 2 i classified as ( ) toxic ; ( ) allerg c ; ( 3 ) septi copyemic . The toxic

“ o cardiac sympt ms closely resemble those found in diphtheria . They

o n come Shortly after the initial defervescence , are often accompanied

o f e . by bradycardia, and are characterized by signs cardiac w akness Usually there is little if any fever and very mild evidence o f general

o o . int xicati n I f the patient remains flat in bed he may give slight , o f o n if any, evidence cardiac weakness , while, the other hand ,

z if he assumes the Sitting or standing posture there occur di ziness , E h weakness and other Signs o f an insufficient heart . sc erich and wh o o as s i Schick designate this conditi n mya then c , state that it practical ly never h as a fatal outcome ; hence histopatholog ical f f descripti o ns are lacking . The similarity o the early symptoms o scarlet fever to those of diphtheria and the possibility o f neutraliz a o f so - o o ru tion the called scarlatinal t xin with an antit xic se m, more over, make plausible the hypothesis that this peculiar myasthenia f cordis is due to a direct toxic action o a poison o nthe heart muscle . The cardiac complication usually placed among the al lerg ic mani fe stati o ns o f o the disease is verrucous endocarditis , pr bably better

6 n o called valvulitis . Schick ( ) adva ced the the ry that the compli cations occurring from the end o f the second to the sixth week after the o nset o f scarlet fever and with greatest frequency about the twentieth day are allergic in nature . This group includes adenopathy,

r recurring angina , nephritis , a thritis and occasionally Simple endo

o carditis ; they are always acc mpanied by fever . Nicoll ( 7) states that endo carditis is practically always a complication of arthritis and “ ” o f designates it a c mplication o a complication . The assumption an o f m that both are m i festations a com on causative condition would , o o h o f . E however, be m re l gical scherich and Sc ick attribute all these sym ptoms to an allergic state which develops as the result o f the THE H EART IN I NFECTIO N . 4 3

prolonged ac tio n o f the causative agent of scarlet fever in the body . At the time of their publicatio n the etio lo gical rOle o f the stre p to c o c

arlatina no t to - c an c us sc e was established , but day we assume with a fai r d egree o f assurance that the stim ulus to the development o f this

o c o hypersensitive state is a strept ccus . Hitc hcock and I have been able to induce a condition o f marked hypersensitiveness in rabbits by inoculating them intracutaneously m o Z with minute doses o f he lytic streptococ ci . insser and Grinnell and Mackie and Mc Lac h le n( 9) have sensitiz ed g uinea pigs with

c rl i Do c h e z and both toxin and intact cells o f strepto c o cus sc a at nae . Stevens ( 1 0 ) have furthermore Sho wn that two types o f hy pe rse n siti ve ne ss c an be induced in rabbits by repeated inj ectio ns o ver long

r l i perio ds with strepto coc c us e y sip e at s to xin . The first to appear is neutralizable with an antito xic serum ; the second is no t so ne utrali z

c an able, and when present be demonstrated by testing with filtrates

o from a variety o f strepto coc ci . Their work can be br ught into relati o nship with both early and late Clinical mani festatio ns of scarlet m fever . The early sympto s may be considered as evidence of hyper sensitiveness to the toxin ; the later o nes as hypersensitiveness to the o o f whole bacteria or to some other bacterial pr duct . A series scarlet o o -m o f V e fever patients sh uld , h wever, be tested fro this point i w

before it c anbe definitely established . Ano ther hyp o thetical angle from which to view scarlatinal carditi s is that these late allergic phenomena o c cur in tho se scarlet fever patients wh o are already partially hypersensitive to streptoco cci and that the added stimulus resulting fro m the scarlatinal infecti o n increases the already existing al lergy to a point wher e clinical sy mp o f toms are elicited . The well kn wn liability o a patient with qui e s ’ cent rheumatic endocarditis to develo p a relapse o f rheumatic carditis f o llo wing an attack of scarlet fever could be explained o n these

. z 1 grounds This liability has been recently emphasi ed by Hector ( I ) . ’ Sinc e Romberg s ( 1 2 ) histo pathol o gical description o f myocardi tis in the diff erent infectious diseases there has been much discussion of

o f c to a the relation these structural hanges the clinic l symptoms , and

no t the heart in scarlet fever has escaped consideration . The resem blance between late sequelae o f scarlet fever and o f rheumati c fever has directed the attentio n o f patho lo gists to wards a comparison of o t the microsc pic pic ure in the two diseases . Schmorl ( 1 3 ) in 1 91 4 stated that he had found lesions cl o sely resembling As c hoff bodies in

. i the heart of a scarlet fever patient St mulated by this finding, 44 HOM ER F . SWIFT , M . D .

Fahr ( 1 4 ) made a detailed study o f the m yocardium in eight fatal o f cases o f scarlet fever, as a result which he concluded that the myocardial alterations in this disease re semble tho se o f rheumatic

o fever more closely than they did th se of any other infectious disease . o f He described them as perivascular granulomas , made up proli fera tive cells from the perivascular adventitia ; cells which were basophilic o N . o i and stained red with pyr nin g ant cells were found , but f o O o b . myolysis neighb ring muscle fi ers was ften present Thus , absence o f giant cells and sm aller si z e of the lesio ns were the chief features diff erentiating these lesions fro m tho se o f rheumatic m y o

a . c o n c rditis In certain cases of rheumati carditis , the other hand , interstitial myo cardial foci were f o und indistinguishable from those

o m o f scarlet fever . Fahr menti ns that the age o f the lesio ns ay be o f significance but leaves the determination o f this questi o n Open fo r future studies . He states that the valves in these hearts were no rmal but that focal thickening o f the mural endo cardium was present in

o f Cz i re r o n e four out nine cases . the other hand , describ d

o o o o o f micr sc pic f cal valvular lesi ns in thirteen cases scarlet fever , and attributed later changes o ften fo und at autopsy to these earlier focal inj uries . While it is evident that the who le subj ect requires

c o f additional study , these investig ations indi ate the many elements

S imilarity between the heart in scarlet and rheumatic fevers . The se p ti c o p y e rni c typ e of cardiac co mplicati o n occurs in those rare instances where th e streptococcus scarlatinae becomes implanted

o and gro ws o nthe heart valve . It is an accident c mparable to other

o f o a forms malignant end c rditis , and only related to scarlet fever because hem o lytic strepto c o cci in general have the c apacity fo r p ro d uc in o f g this type valvular disease .

h ti m R e um a s .

Heart invo lvement in rheumatic fever has interested patholo gi sts

o i and clinicians for o ver a century . Early the close relati nsh p between verrucous endocarditis , pericarditis and what was then

c called a ute articular rheumatism was well established , and the rela tio nsh ip o f acute rheumatic endocarditis to chronic valvular disease o ff 1 was fixed . F llowing the description by Ascho ( 5 ) and by Ge ip e l ( 1 6 ) o f the peculiar submiliary nodules in the myocardi um ’ no w th e o o which bear former s name , the attenti n of b th patholog ists and clinicians was turned chiefly towar ds the myocardium and c o n

6 4 HOM ER F . SWIFT , M . D . diverse cultural and im muno logical characteristics o f the strains of streptococci recovered by different wo rkers added to the difficulty o f bringing them into causative relati o nship with a diseas e which seemed to be such a definite clinical entity . In o ur o wn clinical studies we had beco me m ore and m olre o f a u i impressed with many points resembl nce between rhe mat c fever , i tuberculosis and syphilis , and hence suggested an allerg c explana tion Shortly afterwards Be zanco n and Weil ( 2 3 ) inde pendently advanced similar views . We applied methods which had proved useful in the study of the last two diseases to try to find some new etiolog i c al agent comparable to the tubercle bacillus or the

ne m all um M o f o Tre o id . p a p any species lab ratory animals , including

o a n calves , were in culated in various m n ers without success ful repro ducti o n o f anything cl o sely resembling rheumatic fever and wi thout demonstration o f any new etiological agent . The only micro organisms reco vered with any degree o f re gularity fro m blood c ul

o o tures or subcutaneous n dules were streptoc cci .

DrS . In the past four years , however, in collaboration with Andrewes ,

D r c o e ick and Hit hc ck , we have obtained experimental data with these cocci which appear to have brought s o me order o ut o f what was

o previ usly a confusing situation . The detailed evide nce for o ur work is published elsewhere It is sufficient to state here that by intracutaneous inoculati o n with certains strains o f strepto cocci we have been able to induce in rabbits a general state of hypersensitiveness which resembles in many i particulars the allerg c state seen in tuberculo sis and syphilis . A most im portant requirement for the inducti o n o f this state is the o o pr duction of a f cal lesion somewhere in the body . Lesions repeatedly produced at suitable intervals increase the hypersensitive ness . Once induced it c an often be maintained over comparatively

o ak o l ng periods by m ing a deep f cus of suitably infected agar . The tissue o f a highly hypersensitive animal Sho ws a greatly intensified resp o nse to ino culation with very sm all am ounts o f strep to c o c c i am W o m o o r no ; for ex ple , here a n r al animal Sh ws little

to c c . has reaction of broth culture , the hypersensitive animal a lesio n containing 1 00 to 400 cubic millimeters o f exudate and proli ferate and a highly sensiti z ed animal at times Shows an edem atous

o 1 0 to 1 2 . o o f c c . lesi n mm in diameter following in culation ,

o i ri M while a n rmal an mal Shows only a needle p ck . icrosco pically the lesi o n of a hypersensitive animal sho ws early a much more marked T HE H EART I N I NFECTION . 4 7 exudati o n than i s seen in th e lesion pro duced by the same size ino c u o o f lum in a no rmal animal . But a p int almost as great interest is that an intraveno usly inoculated rabbit does not show hypersensitive

s i . O c nes of th s type n the ontrary , with repeated intravenous immun i zatio n it Sho ws less and less reactio n to intracutaneous test ino culati o n ; and these cutaneo us lesio ns in an immune animal Sho w o less exudati o n microsco pically than do es a no rmal co ntr l . We thus have two types o f tissue response to non-hemolytic streptococci devel o ped ac c o rding to the manner in which the animal is originally o o ino culated : hypersensitive , following in culation int the tissues ,

m o o c . and i mune , f llowing intraven us ino ulation But these two states are not specific when specificity is considered f fro m the viewpoint o cultural or sero logical strain specificity . While a hypersensitive anim al usually reacts more stro ngly to the

z o o - o strain with which it is sensiti ed , it als ver reacts to m re distantly

o related strains . Likewise, an intravenously inoculated animal sh ws the immune type of tissue response to subsequent intracutaneo us t m o inoculation with heterolo gous s rains . A si ilar observati n was made by Kuczynski and Wo lff who observed that intraveno us immunizatio n of mice with green strepto c occi markedly increased a i e wh o their resist nce to hemolyt c streptococci , and by Till tt showed that active immuniz ati o n with rough pneumoc occi rendered o a rabbit immune to all types of pneum cocci . o o f We have , furtherm re , been able to carry some these studies

to o t over into the clinic , and show that m st pa ients with rheumatic fever Show much larger reactio ns follo wing intracutaneo us ino cula

c o r o f o o o o c tions of vac ines nucle pr teins prepared from strept c c i , and

o f no n- o c o c c o o of filtrate hem lytic strepto i , than do n rmal pe ple .

s o Bi rkh au ai 6 The ob ervati ns of g K ser Small ( 35, 3 , and Strauss also indicate similar hypersensitiveness in the rheumatic fever patients they studied . ’ ur o ff o Bi rkh i z o au s v . In one respect bservations di er fr m g , , that patients with active rheumatic fever show Skin hypersensitiveness to 1 f o - o ti M z filtrates o vari us types of non hem ly c streptococci . acken ie ’ and Hanger s ( 39) observations indicate also that the Spec ificity of

c o no t to o ne o c skin rea ti n is linked any type of strept co cus , nor in their observations was any o ne type o f disease linked with hyper

to o sensitiveness strepto cocc i . While they did n t give their complet e

Birkh au o n nfi . co m m c o h as c o m o ur o o g Pers al uni ati n r ed bservati n. 8 4 HOM ER F . SWIFT , M . D .

o f data, it is interesting to note that many their hypersensitive patients were suff ering fro m rheumatic fever . We ( 2 8) have furthermore o bserved that rheumatic fever patients usually Show a late tuberculin-like febrile reaction following intra venous inj ecti on with small doses o f vaccine o r o f nucleoprotein pre

d o m pared fro m hem olytic streptococci . While we not clai that rheumatic fever i s the o nly co nditio n in which these reactio ns are

o f und , still we feel that this kind of hypersensitiveness plays an important rOle in pro ducing the peculiar pictu re o f the disease . Zinsser (40 ) on hypo thetical gro unds h as recently advanced sim ilar o o views . Indeed , we are appreciating m re and m re that it is the peculiarity o f the tissue response rather than a history o f polyarthritis that is the important factor . The recently published statistics of von Glahn ( 4 1 ) emphasize the frequenc y with whi c h rheumatic carditi s may occur in the absence o f a history o f polyarthritis . In the producti on o f most diseases a num ber o f co ntributo ry fac a to a s to rs must be present . As yet we are un ble st te why all per ons to no t i hypersensitive streptococci do have rheumatic cardit s , any more than we c an determine why all s c arlet fever patients d o no t

o o o c sc arlatinae devel p nephritis , or even why s me with strept co cus infections do no t have a rash ; only with the acquisition o f much additional inf o rmation c anwe furnish com pletely satisfac tory answers to these questions . But the existence of a state of hypersensitiveness to streptococci can account for many o f the known features of the o disease . The lack of strain specificity of this state c uld easily make understandable the etiolo gical rOle o f the several types of streptococci that have be en recovered from patients with this di sease . The exten sive exudative reactio n seen in hypersensitive rabbits following implantation of small numbe rs o f streptoc occi e xplains how such relatively avirulent micro- organisms could produce extensive edema and marked outp o uring o f cells in patients who are simi larly hyper sensitive . ’ Fo r a period f o llowing Aschoff s discovery o f the submiliary be i a t ath o lo nodule, which seemed to ch efly a proli ferative re c ion , p gists neglected the exudati ve reaction which is so evident to clinicians in the swelling seen 1n polyarthritis ; but lately the studies o f von Glah n ( 42 ) and Pappenheimer Mac CaIlum and Fahr I o wn ( 4 ) , and our observations (45 ) have directed attention to the a a o f c an import nce of exudation s a part the tissue reaction . I f we assume that the submiliary nodule represents mainly the proli ferati ve

0 5 H OM ER F . SWIFT , M . D . acco unt for the implantati o n of bacteria on the margins of the

o f b w valves . He inoculated two series rab its intraperitoneally ith

c ul staphylococci , and one series intracutaneously by rubbing broth

o tures int o the Shaven skin . Subsequent intravenous in culation with cultures of lo w virulence resulted in the f o rmation o f verruco us

nf r lesi o ns alo ng the valve margin in a numbe r of instances . U o tu l o nate o was . y , a microsc pic examinati n of these lesions not g iven In all of the work of the German scho ol the extension of the infe c

f o tio n o the valve fr m the external surface inward is stressed . In

r th e o f this count y , on the other hand , weight the evidence is thought to indicate that infection o f the valve o ccurs through the vessels supplying the valve . The work o f Kugel and Gross o f the students o f Winternitz o f Kerr o f Bayne-Jo nes o o f and others , all Sh w that vascularization the valves is much more extensive than was formerly known . B o th Gross and Winternitz have f o und that endoc arditis and vascularization o f the mitral valve h e to run hand in hand , and feel that all of t evidence points such

z vasculari ation as being primary . It is interesting to note that endo carditis oc curs mo st frequently in rheumatic fever of ch ildren to at an age when vessels are most numerous , and that liability endo cardial invo lvement decreases with age in abo ut the same rati o as vessels are known to di sappear ; also that frequency of invo lvement o f the respective valves is in direct ratio to demonstrated frequency

z z o f vasculari ation . It is a general rule that locali ation of rheumatic fever le sions occurs most readily in dense co nnecti ve tissue where

o . n there is constant moti n The valves represe t such a tissue . I f hypersensitiveness to strepto co cci o f the vasc ular and perivascular tissue o f the valves o f a rheumatic fever subj ect is at all co mparable o f h i s o r to t to that subcutaneous tissues , that of the hypersensi ive rabbit, it is readily understandable how interstitial valvulitis might arise from implantation of streptococci or their products in these ves sels when the individual is hypersensitive . Indeed , we have observed distinct endo and perivascular reactions in small blo o d vessels in the valves co m parable to Similar lesi o ns in the synovial and perivascular tissue remo ved by biopsy fro m the knee j o int o f patients with active u rhe matic fever . The reaction in the vessel wall may indeed play a larger part in the pro ducti o n o f other cardiac disturbances than we have hereto

o I o f r fore considered pr bable . Fahr ( 4 ) called attenti n to the e que nc y o f s o me form o f vascular lesion in the maj o rity of 32 cases I N 1 THE HEART I NFECTION . 5 o f d rheumatic carditis which he examined , and suggeste that these lesions w o uld account for areas o f transient o r parti al anemi a in the heart wall which in turn wo ul d explain the muscular weakness wh ich e is often so prominent a clinical feature . He go s even farther and suggests that similar vascular alteratio ns may acco unt for some cases o n 6 of malignant sclero sis . V Glahn and Pappenheimer ( 5 ) have still more recently di rected attenti o n to the widespread d i stri buti o no f vascular lesi o ns in rheumatic fever ; and Kugel and Epstein

( 57) have j ust co ntributed Similar valuable additi o nal e vidence . Winternitz and his students ( 52 ) are actively studyi ng the eff ect o f lesio ns o f the vasa vaso rum and po inting out the importance o f these lesi o ns in di sease of the larger arteries and veins in infection . When all o f the work at present in pro gress is co rrelated we may find that the so -called rheumatic fever reactio n has a wider import than we

no w thi nk o . o ti o o f m even pr bable Indeed , the c ncep n rheu atic fever as a j oint disease i s be coming less and less pro mi nent as its rOle in

o contributing to disease of visceral blood vessels bec mes more evident .

ubac ut B ac t ri l En o rd i ti S e e a d c a s .

It is desirable next to discuss the di sease known as streptococ cal subacute bacterial endocardi tis or endocarditis lenta from the stand f ti o Bi rkh a point o recent inves g ations . B th Small ( 35 ) and ug ( 33 ) have rec ently directed attenti o n to the frequency with whi ch rabbits develo p a di sease s o mewhat Similar to subac ute bact erial endocarditis

o c ff n o c i and when in ulated intravenously with indi ere t strept occ , we

o have co nfirmed these obse rvations . Rosen w ( 58) obtained similar o o lesions by inj ecting green strept c cci . But in human pathology this o t bacterial endocarditis is practically always secondary ; in her words ,

c m o n o r r the ba teria are i planted in an abno mal valve , and in the maj ority o f instances the valve h as been the site of an o ld rheumatic endocarditis . Another interes ting obser vation originally made by Kinsella ( 59)

o o f and myself , and c nfirmed by Libman is that all these patients Sho w a fairly high agglutinin titer in their serum against the 6 1 was streptoc occus which is producing their disease . Kinsella ( ) unable to produce endocard itis regularly o n the traumatized valves ’ o f dogs hearts unless he previously partially immunized the anim als . Wright ( 62 ) was able to prod uce bact erial endo carditis more regu o larly in rabbits i f they were previo usly immunized . Wadsw rth 2 M D 5 H OM ER F . SWIFT , . .

( 63 ) has directed attention to the frequency with whi ch horses highly im mune to pneumo c occi develo p endocarditis resembling subacute i 6 bacterial endocard itis in man. Wh te ( 4 ) has recently observed a similar co ndition in strepto coccus immune horses . Serum immun ity and this type of endocarditis se em then to g o hand in hand . We have never f o und a Simi lar high degree of serum immunity in rheu matic fever patients against the strain o f streptoc occi oc casionally o recovered from them . This , more ver , corresponds with our findings e e in hyp ersensitiv rabbits , where agglutinins and pr cipitins against the o al 6 sensitizing streptoc ccus are never very strong . Sm l ( 3 ) and Clawson (65 ) both rep o rt the finding o f weak agglutinins against the streptoc occi which they reco vered fro m patients with rheumatic

lo w . fever, but here again , let us emphasize , the titer was In this co nnection another o bservatio n made by Howells and Co rrigan (66 ) f is o f much interest . These authors found that none o seven patients wi th subacute bac terial endoc arditis sho wed Skin reactions to filtrates

o f o a two . strept cocci , and we h ve confirmed these findings in instances K G 6 o w n n an n insella and arcia ( 7) als ere u able to i duce y . local reactio by inoculating a patient suff ering from subacute bacterial endocarditis c o r o with living strepto occi , by making an agar focus in culated with t hi these s reptoc occi . T s is directly in line with our observations that intravenously immuniz ed rabbits Show less intense reactio ns than do normal animals to cutane ous ino culatio n with strepto co cci or with ? o filtrates . What more do we find clinically Practically n ne of the embolic phen o mena of subacute bacterial endocarditi s are accompanied by extensive e xudation ; but the evidence o f tissue inj ury is closely r co nfined to the area o f the embolus . We have neve seen marked ’ i o f l edem a about a pa nful j o int in the neig hborhood Osler s nodu es , no r about a vessel in the lo be o f the ear where we could observe the e relationship o f the embolus to the bl o od vessel . We have rec ntly observed a patient with this type o f endoc arditis involving chiefly o f e o l the right heart , but in spite num rous pulm nary emboli no pleura o ur e effusion occurred . Another patient recently under care ntered the hospital with rheumatic fever and during the next two mo nths had w all of the exudative phenomena usually seen ith pericarditis , pleurisy to and p o lyarthritis . He then seemed recover but after an acute

o f r c sinusitis developed classical signs subacute bacte ial endo arditis ,

and sho wed S tre p to c o c c us vi rid ans repeatedly in blood cultures . His bloo d which had been saved fro m the period when he was suff ering h from polyarthritis s owed no agglutinins , while that obtained after

5 4 HOM ER F . SWIFT , M . D .

C m — e b intense to destro y them . he o therapeutic measur s have een ff o : equally ine ective , and probably for Similar reas ns the mechanical factors inherent in the gro wth of th e streptoco cci on or in the heart n ff valves are such that no bactericidal agent c a be e ecti vely applied . The Opinio n was expressed several years ago by Lewis and Grant and by Libman ( 7 1 ) that non-h emolytic streptococci probably

o circulate occasi nally in the blood stream o f most individuals . The recent o bservations o f Kugel and Epstein ( 72 ) substantiate this f o pini on . The important factor in the production o disease rests al o f - o o m not one in the presence micro organisms in the bl d strea , but in the ability o f that particular micro- organism to elaborate sub s i t tances which can set up certa n ty pes of tissue reac ion , and also in the capacity o f the tissues to respond in a parti cular manner to f n these substances . In the di fere ces in the response of the tissues b tw e m an we see a possi le explanation be e n the normal person , the sick c r with rheumatic fever , and the individual with subacute ba te ial e ndocarditis .

hi li S y p s .

A brief discussion o f syphilitic heart disease is required not o nly because o f the importance o f the rOle o f the trepo nema pallidum in

o o f o as the producti n cardiac disorders , but als because the dise e rep resents a co ndition where allergy has been Shown to play a prominent part in the path o lo gical changes enco untered during the course o f

o n th e infection . It has be en dem strated that witho ut the develop ment o f such an allergi c state the spiro chetes may be tolerated by the body without exerting a harmful eff ect They c anlie d o r mant in tissues witho ut these tissues showing any evidence o f their presence until the general reactivi ty o f th e body is altered ; then cellular changes in their neighborhood m ake evident the effort o f the bo dy to rid itself o f these foreign invaders . There are also periods o f relative imm unity in co ntrast to hypersensitiveness o n the part o f o C the tissues , as is indicated by the w rk of hesney and Kemp o f Nichols ( 75 ) and others . But with the passage years there develops an increasing degree o f hypersensitiveness so that in an individual where early the general evidence o f the reactio n o f the l o r a - ul l tissues is only a superficial macu e m culo pap e, ater the response is many times as intense in the form o f a nodule o r gumma . I d o no t mean to imply that the late reactions always take the form o f o g ummas , but rather that these lesi ns represent a relatively intense T HE H EART I N I NFECTIO N . 5 5

h form o f tissue respo nse to the presence of spirochetes . T is disease

o e c rOle o f o als repres nts , par ex ellence , the importance of the lesi ns of the blood vessels in inducing alterations in the tissues supplied by them . An appreciatio n of the nature of the evo luti on of syphi lis is ne c e s sary i f we are to find any reas o nable explanatio n of the peculiarity o of the cardiac symptoms . Alth ugh Bro o ks ( 76) and others have directed attention to the frequenc y with which evidence o f cardi ac m ma i involve ent y occur early in the disease , it is clear from stat stical

i o ff as stud es , such as those made by Wyck and Lingg ( 77) as well

f o r a from the experience of clinicians and pathologists decades , th t the baneful eff ects of syphilis on the heart and ao rta are no t mad e a very evident until ye rs after the initi al lesio n . The occurrence of spirochetes in the blood early in the disease has been repeatedly demo nstrated ; hence we m ust co nclude that the heart is exposed to o But as them as much as are the ther organs . it is only after the p sag e o f years accompanied by an ever—increasing degree o f hyper sensitive ness that th e intensity of cardiac tissue response is sufficient to make a marked impairment o f myocardial functi o n clinically

o o - evident . There can be little d ubt that during this peri o d of s cal led latency there may have been Slo wly pro gressing inj ury o f the muscle ; often lesi o ns o f the ao rta and aortic valve have resulted in a c o m e nsato r r c m p y hype trophy of the myo ardiu , but it is only when thi s co mpensati o n fails or when progressive inj ury to the muscle fibers o r o reaches a certain degree , when lesions of the cardiac blo d vessels are extensive enough to interfere seri o usly with an effi cient bloo d t o c ff i . supply the heart muscle, that this mus le fails to work e ect vely Warthin ( 78) has clearly shown how few spiro chetes may be demon strable f i o i in the sites of dif use interstit al my card al lesions , and that c su h lesions are not necessarily in the form of gummas . It is p o s sible that just as g urnm as represent the mo st p erfectly developed and typical fo rm o f marked allergic tissue response to treponema palli s o ff d dum, the Ascho bo y may only represent a typical reacti o n to the o f o causative agent rheumatic fever . In b th diseases there are diff use types of inflam matory reaction and in bo th invo lvement of the blood vessels plays an impo rtant rOle in co mpro m ising the nutrition of the heart . In the manner in which the aorta and the ao rtic valves are

two m o n involved the diseases further rese ble e ano ther . A great ff o di erence in the two , h wever , is the rapidity and intensity with whi c h involvem ent may take place in rheumatic fever and the slow 6 5 HOM ER F . SWI FT , M . D .

o h r ness with which it d es occur in syp ilis ; neve theless , chronicity and perio ds of activity alternating with intervals of apparent latency n e o al are o ften encou ter d in b th m adies .

S e p ti c o py e m ia.

The impo rtance o f septico pyemic invo lvement o f the endocardium consists in the ease with which infected em boli are co nstantly swe pt into the blood stream and thus become carriers o f the bacteria to other h i i parts of the body . There is also t e ad d t o nal picture o f severe intoxicatio n and cachexia which is quickly reflected in a weakening o f the poisoned heart muscle . These are both more deleteri o us factors in d e termi ning the outco me o f the disease than is the ulceration of the valvul ar tissue resulting from the growth o f the bacteria in the endo

o a cardium . In m st inst nces a fatal issue o ccurs before the m e c hani c al f e r e s . factor of ine ficient heart valve , p , can make itself felt

x M ni t ti To i c a fe s a o ns .

It i s often difficult to determine just how g reat an influence a mild poiso ning of the myo cardium is exerting in the abnormal action o f the heart encountered in most infe c tious diseases . The experiments o f Newburgh and Porter ( 79) indicate that the heart may devel o p a type o f resistance to the poisoning that resul ts in Fri edlander bac i l lus m n a pneu onia, for when blood from infected a im ls was supplied ’ o n a o f t a no rmal a im l s heart it quickly showed evidence poisoning , ’ whereas an infected do g s h eart tolerated such blood much better . Levy (80 ) demonstrated that in patients with lobar pneumonia there was usually roentg enographic evidence o f cardiac dilatati o n o f from i ul o f o n ten to thirty per cent . Whether this is a d rect res t toxic acti o f i c o o nth e o r o f some hypo thet al pois n myocardium , a response the o ti o r heart to extra demands resulting fr m the general infec on, a

b c . combination of oth fa tors , is a question not as yet decided That such hearts will Sho w th e usual respo nse to such cardiac tonics as digi talis was clearly demonstrated by the work of Cohn and Jamieson t o n Indeed , it may be s ated as a general propositi n that whe o r c o n in any infection, be it g eneral cardiac , the heart muscle and

to o to th e duction system are badly damaged to respond dig italis , patient is , indeed , in a precarious condition .

H OM ER F . SWI FT , M . D .

’ i n f m n and o R G. : c o o c Co . W. m n . Ed u ds , C , per , A t Cardia Sti ula ts in

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mm o . 1 2 2 . o c o c c . . Strept us J I un l , 9 5, x, 7 5 m an Mc Lac h lan . . n zai o c . . d S : to Ma kie, T J , , D G. Experi e tal Sensiti t n

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THE R THE EFFECT O F STRAIN O N H EA T .

BY H PAUL W ITE ,

s B o ton .

The eff ect o f strai n on the heart has be en a subj ect o f great interest and importance for generations but we are to -day in a better positi o n o e x e ri to discuss it than has been possible before . Fr m laboratory p ments and from clinical investigations have come constantly in recent years new observations which give us a clearer idea o f: the influence

o n u f o of various factors the circ lation , though di ficult pr blems still

ai . o rem n unsolved The arteries , capillaries and veins , muscular m ve i t ments , respirat on and g ravity all have impor ant functions to per form in mai ntaining the circulation and in ai ding in i ts adj ustment to u t as vario s conditions , but the hear must continue to be regarded

i st o f o o the chief mechan sm in the di ribution blood thr ughout the b dy, and as o as we shall see , it must be viewed a d uble organ with the

ff o n o e ect of strain sometimes both sides , but ften preponderantly n o o ne side only . The eff ect o f strain o nthe heart concerns not o nly the experimental

o o c pathol gist, the physiol gist , the general pra titioner and the special a n a . ist in c rdiovascular dise se, but it concer s you all We must know no t only th e eff ect o f strain o n the normal heart but also the eff ect

o f . o n o f o strain on the diseased heart . The subj ect is e large sc pe as we must reali z e that there are not only various kinds of strain a o f r ar and th t each kind st ain may vary in degree, but that the he t

m a r an t d a . itself y va y in its streng h , reserve power , degree of he lth Finally there may act o nthe same heart simultaneously vari o us kinds

an o . so and degrees of strain With m y variables , it is bvious that but a general statements can be made, and these must be applied to e ch indivi dual case with g reat care . Here the experience and wisdom o f the clinician in the practice of medi c ine are of utmost importance in

o f c a o o the weighing evidence whi h will determine the di gn sis , pr g o c an n sis and treatment of disturbances o f the circulation . I here but o utline briefly the effect o n the heart o f strain in general and

o f that of various individual facto rs . The c mplex assembly o individ ual factors in special cases m ust be passed o ver with mention merely o f some of the more frequent g ro upings . 6 T HE EFFECT OF STRAI N O N T HE HEART . 3

Th e d i re c t eff e c ts o f s train o n th e h e art vary ess entially with the kind and degree o f the strain and the c o ndition of the heart to start ff t m with . Slight strain may a ect a diseased hear even ore than

o a o f marked strain a norm al heart . The c nst nt repetition strain ,

o o m that is chr nic strain , may be c pletely taken care of by the cardiac inc re as reserve ; i f it is not, the myocardium must meet the strain by

It o i m o h o t . s s ing in streng h t ne first i pr ved , t en c mes actual increase in bulk with enlarged muscle fibe rs and pro bable increase in capillary

t o u Circulati o n . Whether general cardiac dilata i n and muscle inj ry must always precede actual hypertro phy i s no t yet c lear ; s o metimes o at least this appears to be true . Then with increasing r persistent h strain and decreasing reserve the eart begins to fail . I f the strain is on bo th ventricles the signs o f failure may indicate this — c o nges

o o f o ti n lungs , liver and neck veins , dependent edema , and finally t a general anasarca with ortho pnea and cyano sis . But where the s r in is largely uni lateral then the hypertro phy and dilatation may be largely limited to the right o r to the left ventricle and fai lure m ay start in

c o m i ts o o o ff i that ventri le, the ther aintaining w rk, perhaps t e ect vely

f o r i o . o c o a while , unt l it fails als In a rtic valve disease , hr nic hyper

o o o r e al o tension and ften c r na y disease , speci ly where there is thr m bo si s o f o f o r the descending branch the left c ronary arte y , the left

c o r ventri le hyp ertr phies and dilates , with little change in the ight

c o o ventri le . Then c mes failure with dyspnea and pulm nary o edema and general slowing of peripheral c irculatio n with o edema o f the

feet . I f the fai lure is acute we may have in suc h cases cardiac hm o to o f ast a, pr bably due largely the inability the left ventricle to take c are o f the blo o d being sent to it by th e more Vigorous right

ri c n vent le . In mitral s tenosis o the other hand o r in infarcti o n

to c ff ff limited the right ventri le the immediate e ects are di erent .

c i The right ventri le is hypertro ph e d and dilated . Its failure is sho wn

o f o d in large part by its inability to take care the bl o which it receives .

E o o f c c ng rgement ne k veins and liver, as ites and finally general

. u m o r c c o anasarca develop The p l na y ir ulati n also is Slo wed . The prep o nderant failure o f o ne ventricle do e s not generally last very o o r o l ng, the ther vent icle als fails or the first ventricle reco vers .

e c Wh n right ventri ular failure is added to left ventricular failure , s o me o f the dyspnea and pulmonary oedema may ac tually decrease o f ri but signs ght ventricular failure are added . The balance is a delicate o ne and all gradati o ns and relative degrees o f failure of o r o Dr o . . R either ventricle b th may ccur G . Canby obinson has L . . 64 PAU D . W H ITE , M D recently called our attention anew to the importance of this ventri c ular balance . Acute strai n may be and usually is well tak en care of by the a o r th e cardiac reserve but i f the heart is we k insult a severe one,

o o o o f . as in c r nary thromb sis , acute dilatation the heart may occur This is less co m mo n than the use o f the term itself which has been applied wrongly to all so rts o f conditions such as paro xysmal tachy cardia and synco pe . Heart strain may be intrins i c o r e x tri ns i c i n o rig in and I prop ose to co nsider first the intrinsic factors which are what we generally h o r o o o f . regard as structural defects , lesi ns , and dis rders rhyt m Frequently there is a co mbination o f diso rdered heart beat and dis o r m t eased valve uscle , which results in incapaci y and death where n m nei ther o e al o ne ight be dangero us .

Intrins c trai n A . i S .

o valvular d i s e as e o r I . Let us c nsider first as a conditi n giving ise

o to heart stra1n . Years ag valvular regurgitation and stenosis were

o o f the chief t pics discussed under the subj ect heart disease, then in recent tim es the pendulum swung far to the other extreme and the conditi o n of the myo cardium was regarded as of param o unt im

o a to o fo r p rt nce and fully able c mpensate the valvular defects . No w we appreciate that no matter h o w go od the heart muscle may be it may fail under the burden o f long co ntinued marke d valvular di s ease . We must view with considerable respect a hig h degree o f mitral steno sis or o f aortic regurgitatio n ; aortic steno sis and mitral i m regurgitation are less serious . Slight valvular involvement s c o

i o tal t pat ble with l ng li fe and full physical and men ac ivity, but even in such a case the heart usually shows some enlargement . Generally

“ e o f o o o f speaking, the greater the degr e either regurgitati n r stenosis

a o n any valve the gre ter is the strain the heart , often unevenly dis tributed to one o r the o ther ventricle ; the greater this strain th e

o n f r . o o a Sh rter the li fe Give aortic regurgitati n ex mple, i f the defect is a Slight o ne there may be no symptoms whatso e ver through a

o o strenu us l ng life , the heart may be but very Slightly enlarged and o m the blo d pressure nor al . I f the defect is o f high degree the heart

m m o beco es enor us , the pulse pressure extensive and life is usually

o no a o o o o f sh rtened , m tter what the c nditi n of the muscle, th ugh course a healthy myo c ardium will ho ld out longer than o ne that is

L . . . 66 PAU D W H ITE , M D

o o f decreased wo rk . With the decreased xygenation the blood in the lungs cyano sis appears ; this is probably due to the insufficient ex posure o f the venous blo o d to the alveolar ai r because o f the swell l o ing of the pulm onary blo o d vessels . The pu m nary pressure is x raised and there may be pulmonary apople y . When the right

c lm o o ventri le fails the pu onary circulation bec mes sl wed , there is o f more stasis there because the drop in pressure, but the chief Signs o f the failure appear in the form of engorg ement of the veins o f

i o o f neck and arms , congest n the liver and finally peripheral oedema

o and increased cyan sis . It must be remembered that all grades of mitral regurgi tation and mitral steno sis exist with combinations o f the two . An attemp t has been made by surgery to convert marked mi tral stenosis into a c e r

ai . t n degree of mitral regurgitation , as yet unsuccess fully It is likely l i o o o f o that mitra stenosis and regurgitat n c mbined , each m derate o n t degree, exert a less serious strain the hear than either condition l f i a o ne o . , i f h gh degree

Ao r ti c valve d is e as o b . e acts primarily as a strain nly on the left

o r o . ventricle, whether there is stenosis regurgitati n The left ven tri c l and re ur i e hypertrophies and dilates , but only as it fails mitral g g tati o n develo ps i s there a direc t effect o n the other ch ambers of the

i o o heart , though there is an ind rect and pr bably very imp rtant dele te rio us eff ect on the c o ronary circ ulati o n in cases o f marked aortic regurgitation . Aortic stenosis is a less serious lesion than aortic i o f regurgitation except when the regurgitat on is but slight degree .

o no t o l m It is f und rarely in d people wi th fairly co petent hearts . I as o o o e t regard it a favorable c mplicati n of a rtic r gurgita ion . With aortic stenosis alone clinically or with ao rtic steno sis and regurgi ta tion combined the heart is less enlarged than with aortic regurg itation h with o ut stenosis . Thi s may be due in part to t e bad eff ect o nthe x m i coronary circulation of marked aortic regurgitation . Physical e a X- nation , ray study and electrocardiography all reveal the enlarged o a o i left ventricle f und in m ny cases of chr nic aort c valve disease, j ust as these same methods Show the large right ve ntricle in well marked mitral stenosis . Whenthe left ventricle fails the peripheral C u o irc lati n is decreased , but the first definite evidence usually comes

o o f o o in the f rm dyspnea and pulm nary oedema , and s metimes acute

o m attacks of cardiac asthma, pr bably due pri arily as already stated to congestion o f the pulmonary circulati o n because o f the inability o f the left ventricle to dispos e o f the blo od passed o n to it by the 6 T HE EFFECT OF STRAI N O N T HE HEART . 7

o f mo re no rmal right ventricle . With recovery the left ventricle by

o o m o r rest , rth pnea, bleeding, orphine digitalis therapy the pul m o nar o m o o o r y ede a and rth pnea disappear , the same thing may happen tem po rarily when the right ventricle fails in its turn and

c c u l o t o f blo o d a mu ates in the liver , and edema peripherally , ins ead in the lungs . Ao rti c regurgitati o n associated with luetic ao rtitis is generally muc h m ore o f a strai n o nthe heart than that due to rheumatic end o

i m ro re s . o to o s o carditis The lesi n is apt be m re extensive , it re p g

o o o o o m sive , and there is often ass ciated c r nary rifice inv lve ent in the aortiti s with still greater diminuti o n o f coronary c irculati o n . Alm o st the largest heart kno wn is f o und with marked ao rtic re gu rg i tati o n— c o r z c the bovinum , the Si e indi ating in this instance at least the im p o rtance o f the strain fro m the valvular lesi o n .

Tri u i valv d i e m o c . c sp d e s as e of any great ment is very rare and may be dismissed with the o bservati o n that it ac ts o n the right side o f a e o c m c as the he rt, wh ther sten ti or regurgitant in type, u h does n mitral disease o the left side . When it is present it is usually over

o c m o shad wed by the mu h mo re i p rtant and m arked m itr al disease .

P ulni o n val d . i c ve d is e as e is also unco m mo n ; as an ac quired d efec t it is very rare and whether regurgitant o r sten o ti c in type ac ts o n the right ventri c le much as ao rtic valve disease acts o n the left C ventricle . ongenital pulmo ni c steno sis i f o f high degree is very o a o seri us , is usu lly ass ciated with marked enlargement o f the right

o w o o i c c ventricle , ften ith ass ciated c ngen tal ardiac defe ts and with c n o c o yano sis a d a Sh rt life . The yan sis in such cases is due primarily to the right to left shunt o f uno xygenated blo o d thro ugh a septal d t no t o o efec and to the pulm nic sten sis itself .

2 o n e tal e e . C g ni d f c ts o f th e h e ar t vary very much in the strain

. o o f o r no c s m they cause S me are little Signifi ance , like all septal d c o r c o f c o be o efe ts paten y the du tus arteri sus , to f und only on ro utine physi c al examinatio n ; o th ers are so c om plex and seri ous that

o fo r o o they all w survival nly a few minutes , h urs or days after birth .

e o f There are all degre s strain represented . In general it may be said that the degree o f strain in the victim varies in propo rti o n to the cyano sis . Circulat o ry failure and death in such cases frequently are e m o precipitated by inf ctions , like pneu nia .

3 . P e ri c ard i ti s so metimes acts as a great burden for the heart and o s metimes it too is negligible . There may be a transient unimpo rtant

o pericardial friction rub leaving perhaps a milk sp t , or there may be 6 8 L PAU D . W H ITE , M . D . an extensive pericardial eff usi o n endangering li fe by its rapid i o n accumulatio n w th pressure the heart and great vessels . Para centesis here may save lives but usually the degree of eff usio n is such that tapping is no t necess ary . The ortho pneic po siti o n with great

o a ar distress particularly in breathing, and a marked parad xic l pulse e o o o f ften evidence, aside fr m thoracic Signs , the presence of a mas ff m a s ff sive e usion . The speed o f accu ulation m ke a great di erence a Slo wly gathering tube rcular eff usion m ay be well supported even m o when enor us . Chroni c pericarditis may also vary in its effect o n the heart dependent on i ts degree and locati on . I f the heart is adherent to

o r d o diaphragm, ribs me iastinum and at each c ntraction must pull and On these structures it is under great strain may become very large , m ai nly due to hyp ertrophy of the left ventricle but sometimes of the o f o f who le heart . Some the largest hearts all are found with

o n o i o r o chr ic mediastin pericardit s , grams m re in weight . There may be chro nic obstruction and stasis with engorgement of the ’ o - — o liver giving rise to Pick s Disease . S called cardiolysis a rem val o f the ribs to whi ch the heart i s attached— has in rare cases aff orded

r relief to the overwo ked heart . Frequently chronic adhesive peri carditis is so Slight in degree that there is no heart strain at all and no and o no t e enlargement , the condition theref re may be diagnosabl during li fe . i 4 . Co ro nary d i s e as e whether arterios clerot c or in fectious in nature acts as a strain on the heart by cutti ng down the blood supply . The C o . s greater the degree , the greater the strain oronary anast mose and the effi ciency o f the Thebes ian circulati on may vary very much in diff erent individuals and the same degree o f coro nary disease may thus act very diff erently in diff erent people . Ge nerally actual coro nary thrombosis is a seri o us burden ; it may result in hypertrophy as

as th e o o e well dilatation , latter apparently c ming first, which w uld s em to substantiate recent Opinio n that inj ury to heart muscle may pre cede hypertro phy . Whether lesser grades o f coro nary dis e ase may also cause increase in heart weight is still open to question— it would seem possible that increased demand on that part of the myo cardium which still functions well may cause it to increase in bulk . The strain of co ronary disease may be o n either ventricle but is more a u o r marked usually on the left, especi lly when there is act al cor na y

ma i . thrombosis . The left ventricle y fa l suddenly o r slowly

0 L 7 PAU D . W H ITE , M . D .

Extrin Fac to r . c B si s .

Extrinsic facto rs causing heart strain are o f far less im p o rtance than the intrinsic factors already discussed with two exceptions . r They are hype tensio n and hyperthyro idism .

H e r te nsi o n o r 1 . a y p , either with without renal dise se , is a great burden f o r the heart i f the bloo d pressure remai ns high for a long time . The higher the pressure and the longer it is maintained the

ff o greater the strai n . The e ect is primarily nthe left ventri c le with X - enlargement , found usually by physical examination , ray and elec

r r i r E u t o c a d o g am . vent ally the left ventricle may fail and the sy m p m f m m to s and signs o this failure already entioned ay appear . The ff o f course may be shortened by the coincident e ect coronary disease,

o r o o o o m uremia ther c mplicati n , but a my cardiu apparently in good co ndition and eno rmously hypertro phied may fail because of the chronic burden o f the hyp ertension alone . The hi gher the diastolic

c f h pressure the worse the prognosis . The ause o essential y p e rte n sio n is still o pen to questio n but apparently it is due to inc reased peri

h r l z p e a vascular resistance . Ba ett makes the interesting observati o n “ o o f o 1 2 that I f the minute v lume the heart be kept c nstant , and a per cent diminuti o n in length o f fibers occurred in all Of the arteri ff o f oles since these o er the main part the resistance, the mean pres sure would have to be almost doubled .

2 H e th i i . y p r y ro d sm may be a cause of important heart disease and failure unles s diagno sed and treated early . Even lesser grades undoubtedly increase the work of th e heart but the severe g rades o n i impose a great burden the circulation , w th tachycardia and o increased pulse pressure ass ciated with the increased metabo lic rate . It appears doubtful i f any actu al toxic myo carditis oc curs and the ' ff c x o ultimate e ect may be simply that of cardiac mus le e hausti n . Operation i f properly d o ne generally puts an end to this heart trouble .

. Ex e rc i e nd o rk V 3 s a w . That very igorous exercise and work may pro ve too great a strain for a diseased or untrained heart is unquesti o ned but under proper conditi o ns the mo st strenuous e xertion l i i o f is we l borne by a healthy heart . There s st ll s mewhat o a doubt ’ about the p ossibility of the heart s enlarging as the result of exercise . Abnormal hearts undoubtedly may enlarge —both acutely and c h ro ni

o m o o z cally , but the n r al heart pr bably increases nly a little in Si e at o D Mar e . e n m st ; its reserve is gr at , the champion marathon ru ner , l X- o r shows no cardiac en argement by ray physical examination, but 1 TH E EFFECT OF STRAI N O N THE HEART . 7 so me observations o n pro fessio nal athletes abroad have indicated that there may be Slight enlargement of the heart in professional

ki — m so o m c o m o m s . cyclists , ars en and racers This see s rea nable fr

f c n parison with animal studies . The hearts o athleti a imals are larger than tho se o f no n—athleti c animals o f the same size whether o f ff o m m o r . Fo r the sa e species di erent nes exa ple , the heart of the hare is relatively three tim es as large as the heart o f the rabbit . m o D o Mo o o f Willia Harvey, in his mem rable isquisiti n on the ti n the

s a o Heart and Blo o d in Animals published ju t three hundred years g , “ o o : o wr te as foll ws The m re muscular and powerful men are , the i firmer their flesh , the stronger, th cker , denser, and more fibrous their

r al l hea t , in the same proportion are the auricles and arteries in ”

o o . e respects thicker, cl ser , and str nger It is not likely that hyp r ’ Exe r tensio n al o ne accounted fo r these observations o f Harvey s . cise must be presc ribe d f o r peo ple with heart disease with care but

o t n as already stated , if the heart is c mpe e t a little exercise is probably

o i o beneficial . The poo r physical c ndit on resulting from t tal absti n mc o x c e e fr m e er ise is not co nducive to the best o f health . A man with aortic reg urgi tati o n but o therwise in go o d health and accustomed to so me exercise is likely to be a better risk in a serio us infection o r o h n perati o n t an a lazy fat m a with a no rmal heart . q So -c alle d ath le ti c h e art as n The , I have see it, has consisted Simply “ ” in eff ort syndrome or in an irritable heart in a nervous overtraine d o r undertrained person and not in heart disease . The facto r o f long years o f hard ph y si c al wo r k in the production o f o o e c ronary scler sis is still an uncertain one . Senility, hypert nsion and syphi lis probably played a p art in som e of the cases so designated years ag o . Mi li tary s e r vi c e has so metimes been blamed for the pro duction o f heart disease but practi cally all so ldiers with heart sympto ms and signs c an be sho wn to be l o ng to the familiar groups of eff o rt o f to syndrome or organic heart disease due rheumatic, luetic, hyper

o r r o c m tensive arte i s lero tic facto rs . Rarely ext re e strain in military “ ’ ” r v se ice may perhaps d o direct harm . The usual soldier s heart is m th ff of course Si ply e e ort syndro me .

Te s ts to f determine the e ficiency of the heart , whether of the nature o f o r o c exercise of respirat ry tests , con ern physical fitness as a wh o le rather than cardiac fitness in particular . It i s of interest to no te that in the quiet relaxed upright positio n the heart is under less strain than when the body assumes th e recum 2 L 7 PAU D . W H ITE , M . D .

e o i o to b nt p sit n , due in large part the difference in the amount o f

o o flo w o . ff a n bl d in these positi ns Su erers from cardiac sthma , angi a

o o r o pect ris decubitus , simple orth pnea , appreciate this fact tre m n l e d o us y .

Ac c i d nt 4 . e s do not act as a special heart strain unless o f very unusual nature aff ecting the heart directly by injury or by causing rare valve rupture . When heart disease is f o und after accidents it was alm o st invari ably present befo re but no t recogni z ed or lo oked

r a fo . s m m o Accident y precipitate cardiac sympto s , h wever, as a “ ” o f kind last straw and to that extent may be considered responsible . For the accident insurance board it should be possible to grade the

o m a o o to o o f i s c pens ti n acc rding the resp nsibility the accident , as the

to o to law in Kentucky, and not be obliged , as in m st states , consider

r n it wholly o o t at all resp o nsible . Cardiac accidents and strain m ay readily result from c o ns tipati o n to ff o chiefly due the e rt, which may sometimes be very great, h . t a expended in defecation Here e strain , which is essentially th t V m n i o r car of the alsalva experi ent , may precipitate a gina pector s d iac asthma in a diseased heart altho ugh a normal heart withstands ff o Co o r the e rt easily . itus als may cause angina pectoris o cardiac asth ma o r increase o f congestive failure in a heart with little or no

r rese ve .

n o n . . r n o t 5 P e g a c y . For the n rmal heart pregnancy is a strain

Do o f c ubtless it does increase the work the irculation, including that

o a of the heart , and there may even be s me temporary incre se in

z M e z heart Si e . ost of the apparent incr ase in the si e of the heart

r o s o f o in the late m nth pregnancy is due , h wever , to its upward dis

C c n a placement by the abdo mi nal tumo r . ardia patie ts vary m rkedly in their ability to stand the strain of pregnancy and childbirth . In

o o a l general , they g thr ugh it all right , but each c se must be carefu ly

o c M m j udged by herself and f o llo wed c ns ientiously . arked itral

a o m e stenosis , m rked a rtic regurgitation , arked cardiac enlargem nt and auricular fibrillati o n make terminatio n o f preg nancy advisable ; c o ngestive failure demands such a measure .

6 be i t o ve r ai n fo r a d i s . O s y and e t g are important strains only o n eased heart , but they are ften associated with co ditions like hyp er M o f tensi o n and coro nary disease that cause heart damage . uch the

- C o so called fatty heart is a m isno m er . ardiac sympt ms in an obese perso n may co me from p o or general physical condition with faulty

L . . . 74 PAU D W H ITE , M D

Nutri ti o nal d i s e as e s - u m o IO . , beri beri in partic lar, may cause y i a o and . s cardial we kness , degenerati n failure It possible that in slight degree they may frequently cause some trouble . Hi h lti tud e s e o n o I I . g a xert a definite strain the circulati n , includ to o f ing the heart , i f high enough reduce the oxygen content the o m v to air c onsiderably . S e indi iduals can adj ust themselves easily h t o d o s o f o r igh al itudes , thers with di ficulty , whether not there is al heart disease . It is likely that titudes be low feet impose relatively li ttle burden o n the heart i f healthy but fo r patie nts with i heart failure low alt tudes are desirable .

1 2 Anae s th e sia and s ur i c al o e rati ons r a t . g p exe t a vari ble s rain on the heart but less o n th e heart apparently than o n the nervous control of the circulati on . I f anaesthesia i s well given and op erations are well perf o rmed both cardiac and no n-cardiac patients stand the

a . aro x str in well There are rare cardiac accidents , now and then p

sm l o f l t n y s of tachycardia usual y it le mome t, and rarely failure ; mo st tro uble of ci rculatory ty p e is o f the nature o f shock f o r which n cardiac therapy is o t necessary . It need hardly be sai d that in

i fo r i O tal s . preparat on operation, dig i is rarely required f the general anaesthetics at present ethylene seems to be particularly favo rable o o o f fr m the standp int the circulati on .

I . r e o o f o f 3 Fo c d fluid s . The cust m the forcing fluids much in w s w o c vogue in therapy in late years is not al ay ith ut its drawba ks , n f o o s . s e which is undue train on the heart Thi , i f the heart is weak ,

h o f may actually lead to conges tive failure . T at the ingestion great quantities o f fluid may ac tually lead to cardi ac hyp ertro phy and fail

th e be e r h e ar t E ure is indicated by the occurrence of in urop e . I Al o h l t . c o o bac c o c o e e . 4 , , fi There is little evidence that these substances produce any del eterio us eff ect o n the heart except tran si e ntl o r u its o ff o f y as irritants , thro g h t xic e ect in the case marked

o i o . i t chr n c alcoh lism It is , however, quite certa n that dis urbing dis orders of cardiac rhythm li ke paroxysmal auricular fibrillation may

Exc e s o o f o b . actually f llow overuse alc hol , to acco , or both combined sive use o f to bacco has in so me cases precipitated o r increased angina pecto ris . ’ 1 and . o to e e c t o ne rvo us l 5 Finally , we c me the fi f ( menta emo ti o nal t o s rain . ) on the heart Thr ugh nerve action this is undoubted , and in this present era when nervous strain is almost a continuous one fo r peo ple in many comm uni ties it is doubtless more of a factor o a o o than ever bef re . Business , profession l and s cial c mpetition is TH E EFFECT OF STRAI N ON TH E HEART . 75

o extremely active . The telepho ne and aut m o bile are always exciting

o - ff o o m o o ur . s a e nerves The called e rt syndr e , angin p ct ris , and per

s o o o to inc re as haps hyperten i n and presenile arteri scler sis , appear be

i s ing ; nervo us strain s pro bably in part respo n ible . In add itio n to the facto rs o f cardiac strain that I h ave discussed h o o s no t o o r o o o o t ere are d ubtless ther kn wn p rly underst d , but I have presented eno ugh to sho w the c o mplicated situatio n whi c h may be f o und in a given indivi dual and the care th at is needed in the

o f ai . O o o r analysis cardiac str n n the wh le , h wever , the hea t is an extrao rdinarily p o werful o rgan resisting strains o f all kinds with great ability . COMME O E RE ME O E R D E NTS N TH T AT NT F H A T I S ASE.

BY B H K . R I . J AMES . E R C , M D ,

Ch ic ag o .

In this address there m ight properly be co nsidered the preventive o treatm ent of heart disease . This w uld include the proper manage ment of acute and chronic general and f o cal infec tions who se rela tion to acute carditis and so - called chronic fibrous myocarditis is

to h . rationally assumed , rather than proven , be rat er close There a hi would be stressed the prevention and e rly treatment of syp lis , a o prolific cause o f ao rtic and c ardi ac disease . Ab ve all there would be em phasized the impo rtance of doing what can be done, to guard C o i u o f against rheumatism . o perat on in the international st dy rheum atism wo uld be urged as a privilege and a duty fo r American u o o o f o f medicine . There wo ld also be menti n of regulati n modes

th e o r o o o o f living, in attempt to prevent p stp ne the early breakd wn

o f r m a o r o f . S o the heart valvular o yocardial dise se hypertension , to o o o be c ar , there w uld be noted a gr up that might called potential “ ” d iac s o o r , those who are inclined t ward threatened with heart dis ease and for who m advi ce as to right living may mean much . In th o this class might be put e obese, the gouty , the emphysemat us , the o i o ky ph scoliot c, the pleth ric , the anemic and undernourished individ

ual . t o f , psychoneurotics of certain typ es , and those wi h the stigma hereditary early cardi ovascular degenerati o n . And one would ff t applaud the e or s now being put forth and under contemplation , to learn more o f the essential nature and rational means of handling the degenerati ve pro cesses o f adult and senescent years co ncerni ng whi c h

o c there is s much spe ulation and so little accurate knowledge .

o o o o f I shall , h wever , mit considerati n of these matters prophy laxis . Nor will I dwell up o n the latest advances in cardiac therapy

c m o o f i . o c t surgical , dieteti , edicinal S me the writings c n ern ng hem

o o are understandable ; others seem merely a maze of w rds . S me

as o i r of these newer therapeutic measures strike one pr m sing, othe s

- m as far fetched . All o f them ay better be considere d in the quiet

s o r o r of the tudy , i f attractive , tried out in the laboratory the hospital ward .

o e i o Theref re , d part ng a little fr m the custom , I shall call attention to certain undesirable o r even harmful tendenc ies that are co ncerned rather with the art than with the science o f me dicine . Tho ugh no t

o o f new , they seem w rthy rediscussion at this time when the attention

8 B . K . 7 J AM ES H ERRIC , M D .

No wo nder then that many do cto rs feel that prolo nged rest i s essential in all heart c ases . They get the habit o f prescribing it even

o a o though the heart is frankly c mpetent , merely bec use s me slight

o o . o deviatio n fr m the n rmal has been found . They c nstantly e m ph a

z o f si e the av idance o exertion . Many physicians need to have rem o ved the bugbear fear o f

o o exerti n . It is no new th ught that the h e art musc le after the

o f o subsidence the acuter sy mpt ms may, like skeletal muscles ,

c a no t e s need exer ise ; that wh t is needed in many instances is l s ,

i m r but mo re exerc ise . Pat ents ust be to ld that a rheum atic heart o a leaky valve does no t necess arily im ply a li fe o f inactivi ty and idle

z t f ness . Individuali ation is the key o this feature o treatment . We

n Dr o t . . t i n may all agree with St Lawrence, who says hat w th childre , after an acute rheum atic e ndo cardi tis daily e xercise to the p o int o f to o o f tolerance is be advised , but we must agree with his adv cacy placing a time limit to rest and substituting therefor a system o f training o f the heart musc le so that it may recover its tone and f reac h and mai ntain its maximum of e ficiency . And what abo ut dig italis ? I kno w I am treading o n dangerous gro und when I ventu re to say that there i s a to o stro ng tendency to

o o o o to o f imp se up n the pr fessi n arbitrary rules as the use this drug, rules that are in part c ontraindicated by the every- day results of bed side practice . The fact that so many physicians successfully pre

c i o o f c at b s ribe d gitalis with ut thought units , accurate ody weight, or rate of elimi natio n ; that they use it in co nditions o ther than auri c ular fibrillatio n ; that they d o not refrai n in an urgent situatio n

o m o s r o r fr giving it subcutane u ly, int amuscularly intravenously ; that they very rarely feel co mpelled to give the massive dose in o rder to o m f c — — an c o o o ne get the pr pt ef e t , all this is a protest un nsci us — to be sure against th e to o do gmatic directio ns that have be en given

o e o o publicity , directi ns that are perhaps too much bas d n laborat ry

e h t o o o o o f . experim nt , wit little c ntr l extensive bedside observation The clini c ian o ften kno ws that he c an get go o d results by the intra muscular o r intraveno us ro ute when by the sto mach he is d i sap pointed . He finds at times that i f he spares th e stomach there may not be as muc h nausea th o ugh he does not dispute the statem ent that

o m the nausea and v iting of digitalis are primarily cardiac , and

fl xl o re e t . o y cen ral , in rigin I nstead o f the massive d se, he may pre fer f o r em ergency eff ect the guarded intraveno us use o f strophanthin

r o i — o — o uabain . He th nks sometimes he says he kn ws that he gets results by giving digitalis in co nditions other than fibrillati o n— in COM M ENTS O N THE TREATM ENT OF HEART DISEASE . 79

s o i o o hyperten i n with beginn ng failure , and even th ugh bl od pressure may be still hi gh ; in the failing heart o f pneum o nia and other i nfe c tions ; in valvular and myo c ardial lesi o ns bef o re fibrillatio n h as se t in .

m a . He m ay no t be able to tell y o u why . He y not have a fixed dose ul c th e o He gives till he gets res ts , whi h is rule , we are t ld , that

c m Cush ne y used to tea h his students . In a si ilar manner he gives o ne - o r o f o r his mo rphin . He may try eighth a sixth a grain ; if the

i s o m a - h o r o ne pain severe as in renal c lic, he y give one t ird even half grai n . He is after results .

d m a be to o c ff o f a . I f timi , he y fearful as the t xi e ects digit lis He “ D : D i z e n o Mr . o o kn ws , as ley said rugs are a little iv a p that a ” m c o little mo re wo uld kill ye . S o u h has been said ab ut cumulative

o f c — o fo r o o o and t xic ef e ts and with reas n, the danger fr m verd sing is a real o ne — that many docto rs are deterred fro m using an efficient

M c to o m ff o amo unt . u h s all and ine ectual d ses are not infrequently

o o l i seen . The g d repute of digita is is reestabl shed when there is an increase in the amount and favo rable results f o llo w .

Th e ul o i s o f i o greatest fa t, h wever, the giving dig talis with ut any indicati on f o r its use except th e di agnosis o f heart disease— and this o o m diagn sis s meti es wrong . It may be straying a little fro m th e subj ect o f treatment to refer to the fact that in many of these cases there has been a mi stake in

o h r f N diagn sis t at has led to the unnecessa y use o digitalis . o heart

o o o m lesi n whatever, or an unimp rtant variati n fro the normal , has

re s been regarded as patho l o gical and as dem anding treatment . A

i rato r m o m o r p y arrhyth ia, an increased rate , a faint syst lic urmur a

o o f o ne m to o to suspici n , a cardiac i pulse a little far the left, a blood o to o o o r pressure a few p ints high , a prec rdial uneasiness , these o ther sym pto ms have led to the unwarranted diagno sis of heart dis

t h as e s i c o ur su ease, activi y b en re tricted , digital s pres ribed and p o o o n to e c o o n p sed cardi path is the way b me a c nfirmed euro path .

Ho w ? o s ff does it happen Ign rance , haste , carele sness , indi erence , too great reliance o nX - ray o r elec tro cardio graph will explain many l cases . But I be ieve the greater num ber are to be explai ned by the fact that the do cto r h as a surplus o f ho nesty and is earnestly desiro us o f f making an early diagnosis o heart disease . He has heard fro m h as o teacher, he read in the medical j urnal that the early diagnosis o f

o f o o r i s heart disease as tubercul sis cancer , the great desideratum .

o o In this way and in this way nly , can the seri us cardiac breakdo wn be po stponed . But he has not read of the errors in the diagnosis of heart disease 80 E B K . AM . . J S H ERRIC , M D

o has to and of tuberculosis . He sh uld read what Edouard Rist say

. f m o nthis subj ec t o f erro rs in the diagnosis o pul onary tuberculosis .

’ R o n m o c e r ist s figures , based largely hurried warti e examinati ns , tainly must overstate the frequency of the erro r o f mo re deliberate i ill i exam inati ons in tim e of peace . Yet they are startl ng and um O - i m nating . ne th rd of a large nu ber of cases in France treated for t tuberc ulo sis were no t tubercul o sis at all . Rist quoted Similar sta is

r c M tics f o r England . F iedri h von ueller said a like error had been b o no t G . made in ermany Heart disease and tu ercul sis are the same , yet the mistake o f diagno sing wrongly may in either instance lead to o r t direful c nse quences , unnecessa y fear, lives of inactivi y, enormous economic loss . t to o In this connection , a few words hat have do m re with the f treatment o f the patient than o the disease . There is ingrained in the minds o f most peo ple a greater fear of f a h heart disease than o any other m lady unless it be cancer or syp ilis . To mos t laymen sudden o r dropsical death is im plied by the term Ho t o a . w heart dise se important , herefore , that there be not ar used h o o o i . o w with ut reas n , the th ught of this condit on Yet often the practitioner o r the spec ialist as he examines the chest o r gets the hi s o f tory, arouses the dread something wrong with the heart , when i t o f perhaps there is noth ng the mat er . He may do it by a Shrug o f o o f no t the shoulders , an air hesitati n or perplexity as though

i a o m o n quite understand ng wh t he hears , by a c ment a faint murmur

o r . o o a skipped beat He usually d es this innocently , f rgetting that it i s not always wise to think out loud esp e cially when there is an element o f do ubt o r uncertainty and when there is present an inter

e ste d i . yet apprehensive , mpressionable listener Again when there is s o me real cardiac disturbance the greatest

‘ Em r n h s care is necessary not to convey a wro ng im pression . e so a “ said : It i s no t the fact that imports but the eff ect o f the impression

to k of the fact on the mind . T tell a patient that he has a lea y valve

o r i . e . . a large heart , , that he has heart disease , may be to state a fact Unless this statement be explained to suit the intelligence of the

to c o f o f o patient and a cord with the degree severity the heart lesi n, o be m o o f a wr ng impression may left , the i pressi n a disease that is destined to advance relentlessly to ward an early death . The state

n to ff i . e . me t, truthful as fact, may be untruthful in its e ects , , its

f o impression o nthe mind o the hearer . An unintenti nal lie has bee n as uttered , much an untruth as though the physician finding a definite

organic disease flatly denies its existence .

NGRE D CO SS ISCUSSION .

R DR . E . P . CARTE ,

B a i m re lt o .

I feel as i f to the delightful remarks o f the last sp e aker might be “ added as an epil o gu e the definition o f a specialist— as o ne who ” m o knows ore and m re about less and less .

Dr an o h e x i We are all indebted to . Swi ft d his ass ciates for t is p o s tion o f their studies from wh ich they have ev o lved their conception of the reacti o n o f the heart to acute infecti o ns and especially the

f o m nature o the resp nse in man to rheu atic infection . I feel that I have had a surfeit o f tremendo usly interesting and

m m o c c stimulating facts given e . The sa e questi ns that o ur to me

am o f o u . o have , I sure, occurred to many y It is only p ssible for ’ o Dr i a o me to f llo w . Swi ft s explanat on up to a cert in p int . It is diffic ult for us who have been largely influenced by traditi o n in o ur

o c th ughts , parti ularly in regard to rheumatic infecti on , to dissociate o urselves from fixed ideas and to ac cept readi ly an entirely new hyp o thesis— anhyp o thesis which seems to suggest some very striking parado xes .

i o ut o f o n i i Leav ng c siderat on at this time syphil s and diphtheria , we must no w c o nsider rheum atic infection as a universal vascular — n Dr tissue reaction o f far reaching sig ificance . . Swi ft has presented much sound evidence for a new conception of rheumatic infections and yet o ne that recalls certain Similar suggesti o ns in the older: litera

f to . o w ture I , pers nally, find it very di ficult correlate the idely diver gent clinical picture o f the co urse o f the actual infectio n with the vari o us strepto coc ci with the cardiac response . There is an extra ordinary dissim ilarity o f reacti o n f o und in the cardiac tissue in such clinically different infecti o ns as rheumatic disease and subacute bac

ri l te a endo carditis . Witho ut going into the difficult problems o f immunology and s to allergy , it seem me that the suggestive argument, which was

o o f i o v iced years ago , the Similarity of the react n in tuberculosis

i to u and in syph lis that in rhe matic infections , which we have heard

m m o o co ented up n , at least in their clinical manifestati ns , is of the greatest importance . I wonder , however, j ust how far we can link up the non- sp e c ific reacti o n of the tissues to the imm uno log ically 8 DISCUSSION . 3

diff erent strains of strepto c occ i reco vered in these case s . The inci

f o c o dence o subacute bacterial end arditis , ccurring together with an

o . acute rheumatic infection , is a very interesting and suggestive p int Furth er subacute bacterial endoc ardi tis is so often implanted upon the previ o usly diseased valve o r endo cardium whic h gives evidence

o to o f a previo us rheumati c infecti n . It seems me extraordinary that there is such a rarity of previ o us syphilitic infectio n in the cases of n i subacute bac terial e docardit s . In o rder to crystallise in m y o wnmind thi s questio n of the so -cal led

o o f ss m o allergic resp nse the ti ues in rheu atic disease , I sh uld like

m f o k Dr o . to as . Swi ft a nu ber questi ns ( I ) What constitutes evidenc e o f an allergic respo nse o n the part o f the heart in any bac ? te rial infecti o n ( 2 ) I sho uld also like to ask where is the f o cus in m an which gives rise to the s ensiti z ati o n of the indivi dual as demon strate d c o o c ? IS h o o by the intra utane us in ulation t is f cus in the thr at,

m th e m o c um o r i n is it pri arily in y ardi , in the valvulit s , which has bee

Dr w s o ? ai greatly stressed by . S i ft and his a s ciates ( 3 ) Ag n , is the infec ti o n o f th e myo cardium a primary infec tio n ? ( 4 ) We kno w that the Ascho ff bo dies represent a pro li ferative

o o n o f s o h o o h o f h resp nse the part the tissue , th ug we kn w n t ing t eir

l o h t no t o o exact re ati ns ip to the infec i o n . It may be a pr per questi n

o h Dr o but I Sh uld like to ask W at . Swift c nsiders may be the specific nature o f the Asc ho ff b o dy ?

m a o ( 5 ) One o ther po int suggests itself . What y be the path logy o f the bi c uspid ao rt i c valves o f c o ngeni tal o rigi n no t infrequently enc o untered and upo n which we o c casi o nally find engrafted a sub acute bac terial endo carditis with strepto c o cc us viridans ? Do es thi s co ngenital m alf o rmation represent a prenatal infecti o n ?

f c m o o o . Again , quite far afield , but as an ther bit parative evidence In the literature years ag o s o m e interni st first suggested the relation o f h u ship periarteritis no do sa to r e mati c infecti on . I thought it m ’ no t . Dr vo n l h n was Kuss aul , but I am certain After seeing . Ga s rem arkable slides this mo rning th e re sem blance o f th e diffuse lesio ns to o o periarteritis n d sa suggested itself . It is o f interest in this c o n ne c ti o n o o d o m c c , th ugh far rem ve fr the signifi an e o f the m yoc ardial

o e h a c m reacti n , that Grub r s re ently e phasized the po ssibility o f an allergi c respo nse as underlying the pro li ferative lesi o ns seen in this c o t o ndi i n .

i s o two c o f It p ssible that the quite distin t paths evidence , clinical

o and experimental , are gradually appr aching each other . We have 8 4 DISCUSSIO N .

O f o tw o i s had the evidence a c mparison between the great infect on , tuberculo sis and syphilis and rheumatic disease marshalled with extra o rdinary precisio n ; though I think that the basis o f the evidence D o f o t r . is largely as yet a matter anal g y . As I unders and Swi ft, precipitins and aggluti nins d o no t occur in the experimental animal f ff s infectio ns . It is very di ficult to interpret the widely di erent tis ue respo nse so unlike in the two infections— subacute bacterial e nd o c ar d iti s and rheum atic disease as related to the sam e or to non- sp e c ific Ma c streptococci . y I conclude by expressing my great appre iati on ’ o f o Dr o f the stimulating interest ar used by . Swift s presentation his hypothesis .

H DR . A . E . CO N,

e Y rk N w o .

This discussion f o rms a very Singular and interesting landmark in co nnectio n with our ideas of chro nic heart disease . I f we look back

O o O f 2 o Of Strii m e l O at the pini ns 5 years ago , to the w rk p , sler O f as to and Krehl , heart disease was spoken having been due rheu i a o and mat c fever, sc rlet fever , syphilis , lead and tobacco pois ning, m any other conditi ons with o ut any eff ort having been made to dis criminate between the fo rm s o f natural history of these diff erent n diseases . In the writings Of that day there was a Short chapter o

o o o n o n eti logy, a Sh rt chapter pathological anatomy, a long chapter o f o o fl o w o o n the mechanism the disturbed bl d , and a l ng chapter i physical Signs in referenc e to valvular disease . Th s Shows the di f ference in the attitude o f yesterday and to —day ; it is a matter o f

c No Dr j udgment whether the hange is good . t only has . Swi ft a c o o f m a i dvan ed the the ry an i mune reaction in rheum t c fever , but he has sho wn that different agents are causing this and o ther heart dis eases and also that the pathological anato m y is quite distinct and

o to appr priate each of the separate diseases . We have therefore

f — i o a o di ferences in all three aspects the et logic l agent, the path logical

o m — ff o n anat y and the natural history all di erent , depending the i disease which s present .

Dr . Emers o nhas menti o ned certain interesting factors invo lved in the vario us f o rms of heart disease acco rding to the perio d o f the life cycle in which they fall especially in co nnection with their eti o logy rheumatic fever falls in the earlier decades ; syphilis causes the heart

o f - o lesions middle li fe , while the arterio sclerotic gr up falls in the

86 DISCUSSIO N .

to z o other organs . I want emphasi e particularly the imp rtance of the heart in relation to the respiration and to the vascular system . We i have be en interested in the mech an sm o f cardiac failure . In thi nk ing O f th is matter we have to take into account a number Of well balanced mechanisms that have to wor k tog ether to maintai n the cir o f f culatio n in a state e ficiency and to keep the individual in health .

o The heart underg es many strains and many forms of damage , and the remarkable thing is that it has the ability in the c hang es that tak e place to maintai n the very accurate balance that is necessary for the o resp iration and circulati n . In studying the heart in heart failure and deco mpensatio n we must think o f the heart no t only as a Single organ but also O f its relatio ns to o ther great physiological activities that are going o n in the bo dy and participating in the essential activity o f distributing o xygen

f c o thro ugho ut the body . This point o view has re eived mo re attenti n

o o n o o in the recent investigati ns the circulati n , and less attenti n is being directed solely to the heart than when so much thought and study was being given to the cardiac arrhythmias . In the last few years studies have been pursued which have given m eans of analyz ing

o o : o f further the circulati n as a wh le studies vital capacity , the study

o o f o f Of the utput the heart per minute in man , and the studies

Blum art o n o o f o flo w o o ur g the vel city the bl od , have all br adened

o o o f o to i o c ncepti ns the circulati n and are leading a w der viewp int . The p o int I wish to emphasi z e is that in any co nsideration o f heart

o n e to o strain and its c sequences , it is n cessary bear in mind the vari us physio l o gical activities with which the heart must c o Op e rate in o rder o ai i ff o t m nta n e ectively its functi ns .

H AL DR . ENRY SEW L,

De ve r C n , olo .

A general practiti o ner cannot co me to the treatment O f heart dis

o ease with better experience than the treatment o f tubercul sis . I think we shall all agree that for that treatment we must have per c e ti o n f t p O the activi y of the disease .

a o o c It may be inferred , spe king br adly , that it is not the anat mi al

o o f o limitati ns an rgan that render exercise dangerous , but that

h m alle r morbid c e ical state which has been given the name g y , in

o o o w c which in rdinate resp nse foll s minimal specifi stimuli , with

o o intensificati n and extensio n o f the disease f o cu s . It is pr bably 8 DISCUSSION . 7

i c m o o true that an organ wh h is che ically n rmal , h wever mechanically d O m o f o o cripple , fares best when furnished with a certain ptimu bl d D Mo a o r . supply induced by exercise . re than twenty years g Yan

o O f sh m o f dell Henders n , Yale , publi ed experi ents upon the heart a

s o c o . d o g which are suggestive in thi c nne ti n He found , in brief , that with a slo w rate o f beat the diasto lic v o lum e o f the heart increased

o no t o a o o m but the syst le was c mplete , residu l bl d re ained in the ven

P ari p as s n s tric le at the end o f its co ntracti o n . [ with ri ing frequency in the heartbeat the diasto lic expansi o n o f the ventricles becam e less

and less and the co mpleteness o f systo lic c o ntractio n mo re and m ore . No w rem em beri ng that the c o ro nary blo o d flow which no urishes th e heart is direc tly related to the m o vem ents and the vo lum e o f the

o m to m e m t o fo r rgan , it See s that we may assu e bet er nutriti n the i t u heart that is put thro ugh s pac es as described . In Nat re this is

m M c acc o m plished by the si ple devi c e o f exerc ise . edi al experience “ ” t h o c e t abundantly tes ifies t at in the rgani ally diseased h art , wi h

o m ns c lesions c pe ated and ina tive , these principles are best qualita l ti ve no t o ut o . y , i f quantitatively , carried as in n rmal li fe But f o llo w th at sam e h eart bac k to the tim e of recovery fro m its

c i o sa o o e a first infe t on riginating , y , in a py genic t nsil , the heart app rs

o c o f abso lutely n o rmal to exam i natio n . An ther atta k tonsilitis super n M o w o c an . a venes and s ft murmurs . be heard at the apex y we not suspec t that an allergic organ h as resp o nded to a spec ific stim ulus ? Physi c al exercise a few days bef o re the attack might have be en

no o be a highly salutary ; w it w uld h zardous in the extreme . The heart again beco m es apparently n o rmal ; but agai n and agai n its allergic resp o nse is pro vo ked and the signs O f ti ssue destruction and attempts at repair gradually beco m e permanently manifest on

o examinati n .

O f c an c As in the case tuberculosis , we well suspe t that the ultimate

ff c o f th e hi disaster is the e e t applying right t ng, exercise , at the w o o o o t o r ng time , the peri d including and f ll wing acute infec i n .

DR R H . LOUIS FAUGE ES BIS OP,

Ne w Y r k Ci o ty .

I think this questi o n of exerc ise and rest is very vital to the whole m m matter o f heart disease . I am very uch i pressed by m y own e r c c m o a xpe ience in pra ti e , as to the i p rt nce of exercise to that gro up o f o wh o o m o pe ple of middle age , feel s e prec rdial discomfo rt o n 88 DISCUSSIO N .

o exertion and on that acc unt consult the specialist . I want to make o o ne o o f — this asserti n , that if takes the wh le group middle aged

o O f i o o f business men , Sh wing signs beginning degenerat on sympt ms

m o tw o o s— to the heart , and divides the arbitrarily int secti n the

o o i o to first gr up give nitr glycerin , g ve them instructi ns play golf ,

m o u o and a m keep the t of do rs , m ke the keep up a moderate but reg ular exercise ; take the Seco nd group of patients . with identical

o b e to i sympt ms , tell them to careful , allow them take unlim ted rest and beco m e laz y invalids— m y experience has Sho wn me that while

o the first group is alive and playing g lf and keeping fit, the second

o fo r gr up of patients is in line first class funerals .

DR s . . V E . A LE IN ,

s B o ton .

k Dr o as f . I hesitate t a question o Herrick , especially if it infers a difference o f opini o n ; because I have learned that h i s j udgments are

o almost always sound . I would like to kn w, however , i f he has any direct evidence that work improves the heart . I am very anxious indeed to learn of j ust this ty pe o f evidence . We all know that work o f - produces a sense well being . Playing gol f makes us feel better

z o f w o f a and happier, but analy ed purely from the point vie the he rt

d o I am in doubt whether any go o d is done . I not mean that we tell heart patients no t to wo rk but I do not kno w that w o rk improves the

am o . heart . In fact I inclined to the o p posite Opini n We know that work aggravates the condition when pati ents have heart failure . I f there is heart disease, rest in bed improves the circulation , possibly by r - e establishing the balance between the two Sides o f the heart . The

o f to m laws nature are apt be si ple , and i f it is true that rest impro ves diseased states it would be queer i f the same organ were o no t benefited by the pposite . Exercise does imp rove the breathing capacity o f the lungs ; at least there is no evidence to Sho w that this

so . o is In the case of l ng distance runners , men in the pink of phys

o o f o m o ical conditi n , the vital capacity the lungs is s etimes bel w normal and at others is norm al or abo ve normal . I made such o o o f bservati ns s me years ag o in a group O marathon runners . I have felt that i f exercise improves the breathing ability whic h is the O f f best index circulatory e ficiency, these fellows Should have had l no t. a unusua ly large vital capacity readings , but they did In he rt patients the vital capacity is diminished when failure is present, and

0 9 DISCUSSION .

a o f - small mounts killed streptococci , and tuberculin like febrile

o o l o o reactions fo llo wing intraven us in cu ati n . At times there are als

m a c f o cal c ardiac reactio ns . There y be multiple fo i where the m alle r i z in o e . . o g g substances are f r ed ; g , diseased t nsils , Sinusitis , o abscesses at the apices of teeth , pneumonitis , and p ssibly areas in the m gastrointestinal tract . The rapidity with which improve ent some times o c curs f o llo wing to nsillectomy can be best explained as a result of the remo val o f such an alle rg i zing f o c us ; the fai lure to o btain

m o o n o to th e permanent i pr vement may , the ther hand , be due exist

f o o s ence o o ther foci . Bacterial pr ducts may be dep sited at vario u

o m r o c places in the tissues , with ut any inflam ato y reacti n taking pla e until the entire animal bec o mes allergic ; then m arked inflam mation

o . o to t ccurs It is imp ssible , as yet, state the exact na ure of the o ff o Asch b dy .

H DR . PAUL D . W ITE ,

B s o ton .

( Cl o sing )

o Dr o o o and I w uld like to thank . R bins n for his discussi n especially fo r p o inting out the correlati o n o f the conditi o n o f the lungs and o f i the peripheral circulat on to heart strain . BUS I NES S S ES S IO N OF TH E CONGRES S .

At the co nc lusio n o f the Scientific Sessio n o f the Co ngress a busi ness ses s io n was h eld to co nsid er a change in the interval between the

f o o re c o m sessi o ns o the Co ngress . The Secretary read the f ll wing “ I m e nd ati o n fro m the Executive Co m m ittee o f the Co ngress . ( )

E Co m m o f th e Co s o f m We , the xecutive ittee ngre s A erican Physi c ians o c o m no c o o n and Surge ns , re m end that a ti n be taken the afterno o n o f May 2 nd by the Co ngress and that th e m atter be referred back to the individual co m po nent asso c iati o ns f o r their dis c ussi o n at their next annual meeting and that th eir vo tes be c o m m uni c ate d to the Executive Co m m ittee o f the Congres s . ( 2 ) That the Exec utive Co m m ittee o f the Co ngress be given autho rity to ac t ” in acco rdance with the vo te o f the co m po nent asso ciatio ns . Carried .

o o Dr The Secretary then read a res luti n prepared by . Frank Bil

h Dr m arm al f f to t . C t o lings o C icago be sent o Willia H . New

wh o to s o Haven , was unable be present at this ses i n .

To th e C o ng r e ss : Th is Co ngress was o rganiz ed in 1 887— fo rty -two years n th ag o . Th is is th e fo urteenth sessio n o f th e Co ngress a d like all th e o er m eetings o f th e past is c harac teriz ed by evidenc es o f c o nstruc tive wo rk by all th e c o n o c o n m m stituent ass iati e bers . Th e adm inistratio n o f th e Co ngress h as been c harac teriz ed unifo rm ly by n and o m n effic ie t energy g o d j udg e t . Th is standard o f adm inistratio n h as been due in a large m easure to th e first f o n m r arm al n o n c o th e . C t o f C se retary C gress , Dr Willia Hen y New Have ,

al c I I— i . arm t o m I o o f ne c t c ut Dr . C served as Se retary fr 1 887 until O a peri d - an n o . h n m d th e h m n o f th e twe ty f ur years He was t e ade, is still , C air a m m o n Fo - ar c o o f th e c . r o t tw C m alt h as Exe utive C ittee C u il f r y o years Dr . nan c o ffi c f o n an h i bee exe utive er o th e C gress d s wo rk h as always beeneffic ient . arm al i - h C t no w in h nn . o a . s o m n h is Dr is i ety t ird year Still vig r us e t lly, ph ysic al c o nditio n do es no t perm it h im to attend th is Co ngress— th e o nly o ne

- fr o m wh ic h h e h as beenabsent info rty o ne years . We c antelevisio n th is lo yal m an h i s h o m nh a c a h c nno h e . at e , u ppy be use a t be wit us H h in o n a m d o h h n m T EREFORE, We ere C gress sse bled erewit se d Dr . Willia n Carm alt n — o ur h a W h fo r h i s h h and h n h He ry greeti g e rty is es ealt appi ess , wit ff ” o ur m o ur c and o ur c o n. estee , respe t a e ti

It was then mo ved and seco nded thi s be sent as fro m the Executive m m Co ittee . Carried .

arm alt 2 . C I 1 . Dr died July 7, 9 9 2 9 BUSI NESS SESSION OF TH E CONGRESS .

Dr h s o . . . o Ano t er re o luti n was then read by C W Richards n . “ H in 1 2 6 h o m h th W EREAS , 9 , after a full earing, C ngress deter ined t at e tax

n h c an n th e o c o c Ac t h o c c o p ysi i s u der Harris n Nar ti s uld, in justi e, be redu ed fro m to th e pre -war tax o f and

H R th e n c o m m o f th e o n I 2 8 o W E EAS , Fi an e C ittee Senate, May I , 9 , rep rted to th e Senate a tax reduc tio n bill inc reasing th e tax o f ph ysic ians under th e Harriso n Nar c o tic Ac t fro m to and

H E h no c o n in th e o o nc and no O o r W ER AS , t ere is justifi ati pr p sed i rease p p tunity was aff o rded ph ysic ians to be h eard befo re th e th e Financ e Co m m ittee in o o o n to h nc pp siti t is i rease,

B e i t r e s o lve d th e o n o f m c n h c o , by C gress A eri a P ysi ians and Surge ns , in

o m inth e Of h o 2 1 28 h o o sessi n asse bled City Was ingt n, May , 9 , t at str ng pr test be entered against th is unwarranted ac tio n o n th e part o f th e Senate Financ e Co m m ittee and th at th e Co ngress Of th e United States be urged no t to c o nc ur ” th m m n f in e Rec o e datio n o th e Senate Financ e Co m m ittee .

Drs D M . t After a discussion by arling on , ercur and Alexander

o o Lambert , this resoluti n , which was previously sec nded , was withdrawn .

o Adj urnment .