You do not perhaps know that the Commissioner of Health, Dr. S. G. Dixon, of this Commonwealth, when enforcing the school law which prevents children from attending who have not been vaccinated, because of the ignorance of the public of the great benefits the law would secure to them, and who were so inflamed by a certain legislative aspirant for re-election to office in his efforts to secure votes, was actually followed to the State Capitol by two ruffians, whose purpose was known to assassinate this public officer; and if it had not been that he accidentally left the building by a door which it was unusual for him to use, he would have been the victim of the ignorant rage of an unenlightened public sentiment, and murdered. Had the educational influence of a press bureau of a County Medical Society enlightened that community, Dr. Dixon would have had the co-operation of every man in the region, instead of dangerous antagonism. Whatever is done or can be done, to minimize the prevalence and destructive effects of infectious and contagious diseases, should be made clearly and fully known to the people. And further, the public should be fully informed of any effort to throttle or limit preventive or curative measures.

DR. JOHN G. CLARK, Chairman of the Board of Public Education of the American Medical Association, spoke of the plans being formulated by the Board in the matter of educating the public upon medical matters. Educators and editors generally had taken the most enthusiastic view of the question. A large number of subjects, he said, really required public exploitation, and that efforts were being made to have the large magazines, agricultural and other papers publish articles bearing upon such subjects. It was the aim of the Board, in connection with the Journal of the American Medical Association, that all the articles published for lay people should be bound together or published in pamphlet form. In the event of an outbreak of typhoid fever, if necessary, a certain district might be flooded with literature drawing attention to the necessity of disinfection of water and bearing upon general principles, but not upon treatment. For advice as to treatment, any person would be referred to his family physician. It was the object of the Board to take up the broader phases of medicine; possibly the history of medicine would be considered. All articles wou'd be unsigned.

DR. A. B. HIRSI felt that the proposition of Dr. Taylor, to have the Philadelphia County Medical Society name a Committee on Publicity, should take

practical form, and referred to similar work done by one of the other county medical societies of the State.

DR. JAY F. SCHAMBERG believed that medical bodies should have publicity or press bureaus, and that the work can be done in such a manner as to prevent any abuse; that it would result in a vast amount of good to the public. He gave credit to Dr. Taylor for his courage in braving the attitude of the medical profession by the publication, over his name, of articles in the public press which he thought were for the public welfare. It seems to Dr. Schamberg feasible to have a bureau of publicity composed of prominent men in the Society, who could censor reports given out to the press for publication.

DR. CHARLES A. E. CODMAN endorsed the paper of Dr. Taylor, but thought that since such work was to be done by the American Medical Association, it seemed unnecessary that each county society in Pennsylvania should have such a committee or bureau working independently. He would favor a plan whereby the State Society should have the general control of all the subsidiary bureaus in the State, with the Committee of the State Society working in connection with that of the American Medical Association. He believes there should be such a bureau of publicity, but that the profession should work together, thereby making felt its power.

DR. TAYLOR said, in conclusion, that he was particularly gratified at the spirit in which his suggestions were received, rather expecting some opposition. He was well aware of the work being done by the Committee on Education of the American Medical Association, of which Dr. Clark was a member, and with whom he had conferred. The purposes of this committee, as announced, were to educate the profession through dissemination of information in popular forms, and mainly through the medical journals; also to educate the public in the same way and also in the ordinary channels, as magazines, etc.

His own purpose was to more directly provide the county societies with. systematized avenues of disseminating correct knowledge or current happenings, as well as of medical polity. This object is more urgent, the results in keeping with the true aims of preventive or public medicine, and would tend to emphasize the co-operation of the county societies which are component bodies of the State societies, hence of the National Society. Then the committee, of which Dr. Clarke is one, would be placed in possession of accumulations of facts and opinions from these regular sources.

The Therapeutics of Diseases Which Involve the Internal Secretions

MEASLES:-ITS PATHOGENESIS AND TREATMENT.

BY CHARLES E. DE M. SAJOUS, M.D.

PHILADELPHIA.

THE mortality from this disease is far greater than is generally supposed. In the State of Pennsylvania alone during 1906, 1463 deaths were due to it, 1240 being of children under five years of age. On the whole, it kills two and one-half times more children than scarlet fever, although the latter disease is dreaded while measles is regarded as a benign ailment. Dr. Dixon, our State Commissioner of Health, attributes the serious mortality of measles mainly to the difficulty he experiences in making the public appreciate this danger and the imperative need of precautions that will tend to prevent its spread. When to the danger of death we add the many complications that the disease may entail, it is plain that the profession should attach greater importance to it than it now does, and insist on adequate precautions being taken to prevent its extension. Were this done we might, as Dr. Dixon says, referring to the lack of concern among parents, "save many a home from the sorrow of an infant grave."

4

Pathogenesis. As Osler writes: "The germ of the disease is unknown," though we know that "the contagium is present in the blood and secretions, and in the skin." But how does it awaken its morbid effects? We learn nothing from text-books or from the general literature on this score, and post-mortem findings afford no clue to the process through which the pathogenic material accomplishes its fell work. In brief, it may be said that the manner in which the contagium awakens the symptom-complex of measles is not only quite unknown, but that the question-though its solution would alone afford a solid foundation for rational treatment-has never been seriously studied. In the light of the evidence and conclusions I have submitted in "Internal Secretions," the definition of Measles-and to a certain extent that of other acute exanthemata-is as follows:

Measles is a highly contagious disease due to irritation of the vasomotor center by a virus of unknown origin—probably the toxin of a specific bacillus.

All therapeutists recognize that certain agents, ergot,' for example, cause a rise of the blood-pressure by exciting the vasomotor center. That other poisons, even the product of some bacillus should be capable of doing likewise, is self-evident, since toxins and endotoxins are but prototypes of various ordinary toxics in their action upon the organism. Now, if the symptomatology of measles-a fact which applies to most of the acute exanthematais divided into two clearly defined classes, those evoked by the contagium, and those due to the protective process, it will be seen that the disease per se is the result of excitation of the vasomotor center by its specific toxin or virus. Thus traced to their source, the symptoms of the disease become intelligible. The period of incubation which ranges, as a rule, from 9 to 14 days and most frequently 11, represents that preliminary phase when the specific virus is gradually and stealthily, as it were, increasing in the blood, before the child's auto-protective functions have been awakened. As soon as the actual attack develops, the manifestations of overactivity of the vasomotor center, with the resulting constriction of all arteries and veins and engorgement of capillaries, appear. We thus have coryza, a watery discharge and sneezing, all due to engorgement of the Schneiderian membrane, including its glandular and nervous elements; this applies as well to the mucous membrane of the rest of the respiratory tract including the lungs; hence the pharyngitis, the hoarseness, and the cough. The intense engorgement of the vascular terminals is well shown by the numerous dilated capillaries in, and the redness of, the sclerotic, while hyperæmia of the retina is as clearly suggested by the photophobia. Functional overactivity of the lacrymal glands from the same cause is shown by lacrymation, and if the palpebral conjunctiva be carefully examined, it will be found that in some cases the blood is being driven with such vigor into the capillaries, that its serum transudes through the walls of these vessels, causing conjunctival ædema. The accompanying hyperæmia of the sensory terminals also manifests itself in its characteristic way, smarting of the palpebral borders. The arteries and veins being both abnormally constricted, there comes a time, usually the second day, when, in severe cases, the circulation in the cerebral capillaries becomes torpid; the tissues being then inadequately oxygenized, the child shows dullness of expression and even stupor, while the same condition of the cutaneous capillaries causes the face to appear slightly livid or dusky, and perhaps puffy, owing to oedema.

Why are all the symptoms of the disease restricted at first to the head? My researches have shown that this feature attends more or less all conditions

"Internal Secretions and the Principles of Medicine," 1st Ed., Vol. I., 1903; Vol. II., 1907: 1 page 1383.

in which the vascular centers-vasomotor and sympathetic-are primarily affected by the pathogenic toxic and that it is due to the proximity of the cranial structures to these centers. The excess of nerve-energy developed through the excitation of the latter by the toxic corresponding with the degree of this excitation, a mild case may show involvement of the head and shoulders only while a severe one may spread over the entire body.

Again: Why, if the vasomotor center is the structure morbidly influenced by the virus, are not the capillaries likewise constricted? I have repeatedly urged' an important feature in this connection, viz.: that capillary congestion, hæmorrhages, oedema, etc., are, in many instances, due to the fact that while arteries and veins are supplied with a muscular coat whose contraction is governed by vasomotor nerves, capillaries are not. It is plain, therefore, that vaso-constrictor impulses will affect the arteries and veins only, and that the capillaries must receive the brunt of the tidal wave which the contracted arteries project into them. Again, the contracted terminal arterioles and venules offering undue resistance to the evacuation of the capillaries, these minute vessels become passively engorged-sufficiently we have seen, to produce intense redness, adema, duskiness owing to accumulation of CO, in their blood, etc. In the hæmorrhagic forms, we have clear evidence of intense passive congestion to which the capillaries are subjected; the body may even be covered with purple blotches, blood ooze through the gums, the nasal mucous. membrane, etc., constituting the so-called black measles. Fortunately, such cases are now seldom encountered.

In the average case, the third day may be characterized by a respite during which all the acute symptoms subside. This is but the lull before the storm, however, and by evening the symptoms described return with renewed vigor, accompanied perhaps by rapid breathing, dry bronchial wheezing, and a hoarse croupy cough which may signify the presence of laryngitis with œdema, and be attended with alarming accesses of dyspnea, or laryngismus. More or less severe pharyngitis with oedema of the palatine arch, and dysphagia, are generally present with some enlargement and tenderness of the parotid and submaxillary glands. All these symptoms are obviously due to excessive hyperæmia and infiltration of the cellular tissues.

About this time, and sometimes on the third day, what is known as "Koplik's sign," appears on the buccal and labial mucous membrane, viz., bright red spots, varying in size from a pin-head to a split pea, each of which is surmounted with minute pearl-white specks. These are the precursors of

"Internal Secretions and the Principles of Medicine," 1st Ed., Vol. I., 1903; Vol. II., 1907: 2 page 19.