at the present time is that she feels continually as if she were drunk. Referring to the literature, we find that this vertigo is very often a characteristic early symptom. Two months ago, or a month before she was seen, the back of both hands peeled off in small scales, and prior to that time they had been quite red, and when we saw her, the skin of the back of her hands had a peculiar parchmentlike appearance, erythema, and the appearance of sun-burn extending half way up the arm.

The second characteristic symptom in her case was a chronic diarrhea for the past six months. The stools have been the color of red clay, without blood, and have averaged from four to six per day.

The third characteristic symptom in her case was a condition of melancholia, which to a stranger talking with her, as I was, was not really marked. The physician who brought her, however, said that there had been a distinct mental change, and her family had commented on it. She had no stomatitis when seen, although she did have a gum boil.

Complete physical examination of the heart, lungs and abdomen was negative. No ataxia of the upper or lower extremities. The reflexes were active, but not exaggerated, and her blood showed a slight degree of secondary anemia. The red count was 4,952,000; leucocytes 6,600; hæmoglobin seventy-three per cent. The differential count showed slight increase in the proportion of polymorphonuclear neutrophiles, as in one of Dr. Parker's cases. Examination of the urine was negative, except for an excess of indican. A careful examination was made of the stools, and this was negative for eggs or parasites of any kind, and simply showed an excessive quantity of mucus. The case was seen by Dr. Tucker, of Richmond, who believed there was a distinct mental change, and that these symptoms were not due to the menopause--as she was at that time of life, in the fifth decade.

Dr.

Since she returned home, her condition has grown progressively worse. Smith, who was in town two days ago, phoned me that the hands have peeled or exfoliated the second time, and that she has developed a very intense stomatitis, which is one of the characteristic symptoms of the disease; that she has continued to lose weight, and that her mental condition has become more serious.

I mention this case simply to show that, in all probability, we have pellagra in the State of Virginia. One very interesting thing, which I came near forgetting, however, was the fact that there was no history of the ingestion of corn in this case. The woman said that in her family they do not use corn-bread, and she does not believe she has eaten corn a half dozen times during the year. There was also no history of the drinking of corn whiskey.

DR. REA PARKER, Williamsburg, concluding the discussion:-There is one question I would like to ask, and that is relative to the condition I reported in the first case, after this very slight convulsion, the rapid dilating and contracting of the pupils, first one and then the other, without any external stimuli. I do not know how to account for that. If it were both pupils at the same time it might have been due to hallucinations, but it was first one and then the other, and I do not know whether that was a brain condition, or a spinal condition, or not, and I would like to ask for information if anyone can give an explanation of that.

BACTERIA IN THE CIRCULATING BLOOD. WITH DESCRIPTION OF TECHNIC FOR DEMONSTRATION BY STAINING METHODS.

By M. P. BURNHAM, M. D., Harrisonburg, Va.

In the study of the blood many advances have been made during the past decade. As a result of perfected methods in blood culture technic, supplemented by animal inoculation experiments, nearly all of the acute infections have been proven to be true bacteriæmias.

The vegetable pathogenic micro-organisms, as a class termed bacteria, have heretofore been studied by the use of cultural methods and animal inoculation tests exclusively. Staining methods in the past have not been found applicable to the study of the bacteria in the blood. By the use of cultural methods the characteristic bacterium has been isolated from the blood in the following diseases; Typhoid and paratyphoid fevers, pneumococcus infections, gonnorheal sepsis, acute tuberculosis, malignant endocarditis, cerebro-spinal fever, bubonic plague, glanders, anthrax, cholera, Malta fever and in the various septicemias due to the pyogenic cocci.

The animal pathogenic micro-organism, the protozoa, are, from the nature of their life history, not suited to culture study. The protozoa causing trypanosomiasis and the spirochete pallida found associated with syphilis have both been cultured by certain observers. As an aid to diagnosis this culture work has been of little value, and for the demonstration of the protozoa in the blood, staining technic has been relied upon. Malaria offers the best known example, and in trichiniasis, trypanasomiasis, filariasis and syphilis, the protozoa have been demonstrated in the blood by stains.

Briefly, I wish to consider these two methods of study of the blood, not from the standpoint of the bacteriologist but from that of value as practical diagnostic aids in the hands of the physician doing general work.

At this time the bacteria are the best known and most important infective agents. But in two diseases only of the considerable number of diseases known to contain, in the circulating blood, the micro-organism causing them, has the use of a culture technic furnished a routinely applicable diagnostic test of importance, viz: typhoid and paratyphoid fever. In the other above-mentioned bacteriæmias, results of cultures as now made are far more apt to give negative results than otherwise. In try days of the disease when of the er fully ninety-five per cent. of all cases greatest diagnostic val Why are no similar results obtained in the other diseases in which the bacterium has been isolated from the blood? Mainly to the following factors are

give positive cultures,

able culture media, is inqulture work to be attributed: Unsuit

in one of many requisites, too few bacteria

in the amount of blood used, some of which are dead and others dying, and lastly to the bactericidal action of the blood itself. The negative culture is the bugbear

of the laboratory investigate standpo

Considered now from

of general applicability, the use of cultural methods offers even greater obstacles than those met in their application to the study of disease. In medical centers only where the facilities found in a fully equipped laboratory are available as well as trained investigators, can the work be carried on. As personal contact of patient and investigator is in nearly every instance necessary, the narrow influences of culture studies can be easily appreciated. The larger percentage of our population being in the rural communities, the general practitioner working among them, mainly removed from medical centers, gets little assistance from this work at this day and time.

Staining methods of study on the other hand are far more simple of application and generally give less positive data. For their successful use is demanded either a micro-organism having definite morphological characteristics or one taking a particular staining reaction. The various protozoa fulfill these require

ments. The bacteria do in a few instances also.

The employment of stains for demonstration of bacteria in the blood is open to every man who has a microscope and a desire for accurate information. No expensive equipment or high technical knowledge is required; neither is any amount of time required in making the observations.

The use of stains offers one material advantage over that of culture methods in that it allows of morphological study of bacteria as they appear in the blood unaltered by growth under artificial conditions.

The search of centrifugalized laked blood for bacteria is one of the older laboratory procedures which has fallen into disuse until the past twelve months. Herrick and Janeway demonstrated in April this year the presence in the circulating blood of the ova of the trichina spiralis. Rosenberger, Forsyth and others have reported the finding of tubercle bacilli in the blood of many cases. Burnham and Lyons reported in May the finding of typhoid bacilli in the blood but failed to confirm the work of those men who had found the tubercle bacilli in the blood.

The technic which we found in our work to be the simplest as well as the most uniformly satisfactory is given below. Many different methods were tried out, but for one reason or another were discarded. One to five c. c. of blood was used in our work and taken from a vein in the arm or from one on the dorsum of the foot by means of an ordinary hypodermic syringe having a capacity of at least five c. c. In some of our work blood was taken from the ear after a deep stab with lancet either by use of a pipette or by dropping direct onto a glass slide.

The field in every case was carefully prepared to exclude surface contaminations. Thorough scrubbing with soap and water followed by a saturated solution of bichloride of mercury which is removed by free use of ninety-five per cent. alcohol. The blood withdrawn is immediately transferred to a one and onehalf per cent. solution of sodium citrate in normal salt solution to prevent the occurrence of coagulation. This blood-citrate solution was centrifuged for ten minutes at a moderate speed. The sediment thus obtained was placed on clean slides and dried by moderate heat. In this work it is absolutely necessary to prevent any contamination from any source. To clean slides perfectly use soap and water first and then place in commercial nitric acid and allow to remain for twenty-four hours. Rinse in distilled water and bring to red heat in a Bunsen flame. This removes all matter from the slides. From the dried thick smear of blood, it is now necessary to get rid of the blood pigment. The presence of this pigment in the erythrocytes makes it impossible to apply any stain that will show such small bodies as bacteria in the film. Several methods of removing this pigment have been used by different investigators but the one we found to give the best results-although a somewhat slow one-was the use of distilled water into which the slide was placed and allowed to remain three hours. On removal, practically all of the pigment is found to have been dissolved and passed into solution. Care in using distilled water for laking as well as for the making of the citrate solution is necessary to prevent contaminations. The water if allowed to stand we found almost uniformly to contain vibrio and acid fast bacilli. To prevent contamination from this source it is necessary to use containers that have been cleaned in strong mineral acids and to take the water direct from the still. After the laking process, the slides are allowed to dry and then stained-the stain used being the one best adapted for the demonstration of the organism sought for. The entire procedure can be carried out in twenty minutes excepting that period of three hours when the spread is being laked.

By this technic ten cases of typhoid, five cases of pneumonia and ten cases of pulmonary tuberculosis were studied. In all cases from six to twenty slides were made and examined.

In the ten cases of typhoid studied we found in six a Gram negative bacillus resembling the typhoid bacillus morphologically. These all gave positive cultures. Of the four cases in which we failed to demonstrate any micro-organism in the blood all were examined late in the disease. Two only gave positive cultures. In three of the cases in which we were able to demonstrate the Gram negative bacillus we also found them in spreads of blood made direct from the ear and no use of citrate solution was made. This is too small a number of cases to draw definite conclusions from. I am inclined to believe that this technic will afford us a method as valuable as staining methods now used in demonstrating the malarial parasite. No diagnosis between typhoid and paratyphoid fevers will be possible by use of stains. A thorough search of the literature has failed to show any results such as reported here in this disease.

In the five cases of pneumonia studied by this technic no diplococci were found. It is, however, probable that the blood used was taken too late in the disease and did not have the cocci present. In two of the cases the blood was examined on the fifth day; in two on the sixth day, and one on the seventh. Blood cultures made in two of these cases gave negative results. Blood from the ear was used in four cases and from the vein in one. In pneumonia, blood should be examined in the early stages of the disease and not less than five c. c. should be withdrawn from a vein. I believe different results will be obtained under these conditions than we met with.

In the ten cases of pulmonary tuberculosis studied by a technic in the main similar to that above described entirely negative results were obtained. These cases were in various stages of the disease and all had tubercle bacilli in the

sputum. Five c. c. of blood was used in every case, and many slides in each patient examined with failure to show one tubercle bacillus. The tubercle bacillus having a definite staining reaction, offered favorable conditions for demonstration if present in the blood. I have had no opportunity to use the technic in the acute forms of the disease. It is only in these acute tubercular processes that culture work has demonstrated the presence of the bacillus in the blood.

By accident, two cases of malaria were studied by this technic, and by the use of the Gram stain the pigment of the protozoa was seen under the microscope as small areas of granular matter taking a yellowish brown stain and in quite a distinctive manner. Had we not a better way of demonstrating the protozoa this technic would be of value.

In concluding I want to state that this is not a method employed in clinical laboratories routinely. From the limited amount of experience I have had in the use of it no definite conclusions can be drawn, but I believe it has great worth. It gives to the practising physician means to investigate the blood for the presence of bacteria which heretofore, by reason of the complicated technic of cultural methods, he could not avail himself of.

Great vigilance is to be observed in excluding contaminating micro-organisms from external sources. Already some published reports of investigations made using this technic seem to be open to criticism on account of faulty methods in this regard.

Definite data are greatly needed concerning the presence of the bacteria in the blood, as well as to their life history while there. When the blood stream is invaded in the various diseases, and in what numbers, are interesting questions concerning which we are at a loss for information. Upon the presence in the blood, their numbers, and their history while circulating in the general blood stream depend many of the questions concerning immunity in its various phases, the explanation of which is awaiting solution. Methods of treatment are likewise dependent for their proper application upon these factors largely. Study of the bacteria in the stained film cannot fail to give data upon these points.

THE CLINICAL SIGNIFICANCE OF AEROPHAGIA.

By DOUGLAS VANDERHOOF, A. M., M. D., Richmond, Va. Adjunct in Medicine and Lecturer on Physical Diagnosis, Medical College of Virginia.

One of the most common complaints of patients suffering from so-called indigestion is belching, or eructation of gas. These patients frequently say that everything they eat "turns to gas," and they occasionally volunteer the information that they are afflicted with "gastritis." They invariably believe that the condition is due to the fermentation of food in the stomach, and in most cases they have been treated with restricted diet and a variety of drugs by physicians who also believe that a process of fermentation is responsible for the symptom. The purpose of this paper is to show that the gas which these patients expel is nothing but atmospheric air, in the vast majority of instances, and that the condition is directly dependent upon the fact that these patients all unconsciously swallow the air with their food or between meals.

Ærophagia, or air-swallowing, is seen in its most striking form in hysterical subjects and in other individuals with well marked neurotic stigmata. In such cases enormous volumes of air may be expelled. Instances are on record of patients who have belched over 5,000 times in twenty-four hours; and the amount

of air eructated has been measured and found to exceed 200 litres. It is quite evident in examples of this kind, that the quantity of air expelled is many times in excess of that which could possibly be produced by any conceivable process of fermentation. Furthermore, the air expelled in such cases has been collected and analyzed by several investigators who have shown that it approaches in composition atmospheric air, being composed almost entirely of nitrogen and oxygen with an admixture of but a small quantity of carbon dioxide, the latter being derived from the decomposition of the carbonates in the food or in the alkaline saliva.

This interesting condition was first described in 1814 by Dejardin who cites the case of a conscript who, in order to escape military service, swallowed large quantities of air which produced abdominal tympanites. Since that time a number of writers have maintained that air can be introduced into the stomach during respiration and more so during deglutition of saliva and food. Bouveret, in 1891, published an elaborate discussion of the mechanism of this affection and gave it the name ærophagia. The condition, as it occurs in the extreme cases, has become a well known clinical phenomenon. The eructations are almost always accompanied by more or less noise and the condition is a distressing one to witness. The worst case I have seen was in a young newspaper reporter who had attacks when he would belch for several hours at a time. The act was accompanied by a to-and-fro movement of the head and each time it came forward he would let out loud reverberating sounds that could be heard throughout the length of a large hospital ward. I saw a second marked case two summers ago in a stout woman who was accosted by a negro while walking alone in a country road. She was greatly frightened and ran the distance of about three city blocks to reach her hotel. For a month after this experience she suffered intensely with abdominal distention and flatulence so that she walked the floor a good portion of each night. The "cure" in this case was most interesting in that the condition absolutely disappeared in thirty-six hours after she was told that she was swallowing air. She had a "relapse" about a year later while undergoing treatment in the hospital for a nervous tic, and her abdomen became so distended that she reminded one of a toy balloon that would rise out of the bed at any moment and go bumping against the ceiling. In this article, however, it is not my intention to discuss these extreme cases, but to show that air-swallowing is a very common affection and occurs to a greater or less degree in the majority of cases of the "false gastropathies" and other forms of so-called indigestion. A most excellent article on the subject of ærophagia, together with a very complete bibliography, is that by Spivakt, of Denver, Colo., to which the reader may refer.

It is interesting to reflect for a moment that the phenomenon of swallowing air is not limited to man alone. Other animals, especially the horse, are subject to this affection. In the paper to which reference has just been made the author quotes a communication from Mr. A. M. Farmington, Acting Chief of the Bureau of Animal Industry, U. S. Department of Agriculture, which deals at length on this subject. "Indigestion, or dyspepsia [in the horse] was formerly attributed as the cause of air-swallowing, but later observers have more properly classed it with the vices; and in the same category with a considerable number of other whims, bad or vicious habits, resulting in most instances from idleness, which the horse, free from restraint, incessantly repeats without any other motive in reality than the gratification of desires which finally become imperative, but which always intereferes with his complete serviceability. The modes by which the horse accomplishes the act of air-swallowing are known by the names of 'cribbing' and 'wind-sucking.' Usually, in cribbing, the horse takes a point of support or contact for his upper incisor teeth, which causes an abnormal wear of the teeth, and the vice can thus be detected. Less frequently he 'cribs' in the air, without taking a point of contact, and is what is called a 'wind-sucker.' To crib in the air, the animal begins a rapid up-and-down movement of the lips, then suddenly lowers his head-sometimes to the level of his knees-and swallows a mouthful of air; most frequently with the production of a guttural sound, which has sometimes been wrongly interpreted as an eructation. When the effort is not successful, and is confined to the simple act of deglutition of saliva, the attempts are renewed until the desired satisfaction is secured. †Spivak, C. D. Erophagia and Flatulence. Medical Record, N. Y., 1905, Vol. LXVII, pp. 649

655.