ancholy spectacle of a man hoping to find himself a syphilitic. Nothing in his physical history, however, could be interpreted as syphilis.

His blood was examined and 70 per cent hemoglobin, 3,300,000 red, index 80+ and 10,000 white (three hours after eating) were found. This made it still more improbable that the disease was syphilis, for even tertiary syphilitic lesion of the magnitude of those present would have stirred up more of a leucocytosis than that found. In addition to this much evidence, the examination supplied us with a valuable index of the patient's general condition. Notwithstanding the apparent validity of the patient's venereal alibi, he was placed on iodides, upon which he has continued for months without effect upon the tumors.

Skiagraphs show the tumors to be of osseous origin. They are probably sarcomata. The most perplexing peculiarity of the case is the symmetry of sites in both forearms.

I am rapidly approaching my time limit, so let us turn quickly to a case where the blood examination was of more direct service.

Little Helen M., 8 years of age, was taken ill quite suddenly after having'skipped the rope" without rest from the school-house to her home, a distance of almost a mile. On reaching home she sank breathless and exhausted, would not eat supper, and in the night developed a severe pain in her left side and a high fever. At 2:30 a. m., a doctor was first summoned, when the little patient's temperature was found to be 102.5 deg. and her pulse rate 150. The condition of the heart was alarming. It was intermittent, irregular and excited. Considering the history of over-exertion, the possibility of acute dilatation were imminently in mind, although no organic lesion could be demonstrated with the stethoscope. The pulmonary second sound, however, was much accentuated.

Pulmonary resonance was slightly diminished, and next day the patient began to cough slightly, the desire being inhibited by the pain in the side. Her temperature rapidly mounted to 105 deg. It was necessary to entertain in mind the possibilities of pneumonia, simple pulmonary congestion and acute heart lesion.

A leucocyte count of 40,000 confirmed a diagnosis of pneumonia. On the strength of the high count a favorable prognosis was ventured, and this in spite of the gravity of the patient's general condition-the temperature hanging about the 105 deg. mark, and the heat being markedly embarrassed. Within a week resolution began and the patient passed through an uninterrupted convalescence to recovery. The point of particular interest in this case is the venturing of a favorable prognosis on the strength of a high leucocytosis in the face of grave clinical aspects.

The case of M. may prove of some interest to the surgeons present. Some three or four weeks prior to the time now concerning us, he had been operated on for acute mastoiditis. Instead of pursuing a course like its favorable beginning his convalescence was interrupted by the appearance of symptoms alarmingly suggestive of intracranial infection. He became dull mentally, was restless, nervous and lost the appetite he had regained

soon after operation. He complained of great pain in the head, desired the room to be kept darkened, and his temperature chart exhibited sudden rises in the curve, preceded by chilliness. The spinal reflexes were all increased. The thermometer, however, exhibited to the surgeon an indefinite periodicity, evident in the fact that the general averages of temperature on alternate days were comparable one to the other.

I need not mention the difficulties attending the diagnosis or exclusion of intracranial infections in complicated cases of mastoiditis, and the value of the blood examination in this instance will be appreciated to the full extent by all familiar with the difficulties and perplexities besetting the surgeon in such cases.

Upon the suggestion of Dr. Sampson, an examination of the patient's blood was made and the following condition found: Hemoglobin 75 per cent, reds 3,600,000, white 12,000. A search for plasmodia was without result. However, the low leucocyte count was contradictory to a diagnosis of intra-cranial infection. The administration of quinine was continued and the patient soon after cleared up and has progressed to complete recovery.

In the case of Nellie W.a leucocyte count of 11,400 was found. This was a case of rather painful mastoiditis without acute symptoms. Upon operation a densely eburnated mastoid was excavated. The whole aspect of the case was that of chronicity. It serves to illustrate the unreliability, for diagnostic purposes, of the leucocyte count in certain slow inflammatory conditions.

In the case of Fred W. the examination was made five and a half days after the patient, a boy 12 or 13 years of age, had been bitten by a rattlesnake. At the time of the examination, the aspects of the case were anything but cheerful. In general appearance, the child seemed exsanguinated; he was blanched and colorless from toes to finger tips. Along the inner aspect of the leg, from the seat of entrance of the venom in the foot to the groin, the skin was purple and discolored. The temperature ran from 100 to 101.5 deg., the pulse from 120 to 170. The blood pressure was very low and there was present over the cardiac area a marked anemic murmur. Ten hours before the examination, the patient had had a convulsion-the exact nature of which it was impossible to determine. A few hours before, the patient had been siezed with severe epistaxis, for the control of which Dr. Coltrane, of Afton, had packed the nasal cavities. It was necessary to maintain the packing in position constantly, for the blood had lost all virtue of coagulability.

Examination of the blood revealed but 30 per cent of hemoglobin; there were 1,800,000 reds and 30,000 whites. The fresh blood exhibited under the microscope many interesting departures from normal. The red cells were all well formed, but floating about in the plasma were many "shadow cells." For a full twenty minutes, the blood lay upon the slide before beginning rouleaux formation. Fibrin formation was astonishingly slow. I watched the slide for fifty minutes for the formation of fibrin filaments, but finding none, gave up the search for lack of time. The drop upon the ear was fluid for twenty minutes.

The length of time since the reception of the venom and the good formation of the corpuscular elements lead to the making of a guardedly favorable prognosis. Theoretically, the deteriorative blood changes had about extended to the time limit and the gross peculiarities of the red cells, as seen in the fresh blood under the 'scope, were indicative that deterioration of the corpuscles was not actively in progress. Examination of a fixed smear next day failed to disclose any granular degeneration of the erythrocytes and reassured the prognosis already made. It was reasonable to suppose that, if the boy could survive another 48 hours, he would recover altogether. It is with pleasure that I say the boy is alive today. To me, this case has been one of great interest, and the rarity, in this country, of the lesion will make it a matter of interest to many others.

Before closing, I wish to cite one more case, that of T. J. D., aged 54 years. The history of this case is rather peculiar. Five years ago he sustained an injury over the abdomen, after which he had suffered with periodic digestive disturbance associated with obstinate constipation. Four years ago he was examined in Chicago during a period of obstipation and a diagnosis of ileus was made, together with the prognosis that the patient. would live but a short time. However, he recovered from the attack, continuing in fair health, between periods of intestinal and digestive disturbance, as mentioned above.

Three years a tumor in the left lower quadrant of the abdomen first became discernible. It was movable, painless and of slow growth. Of late, another tumor has at times been demonstrable near the site of the first one. During the last six months, a tumor has developed in the epigastrium, somewhat to the left of the median line. It is dense, movable and of some size, for the fingers may be passed down its lower surface a distance of perhaps four inches. It is not painful.

The temperature of the patient is elevated from one to two degrees. The appetite is variable, being at times fair while at other times the patient is nauseated for several days and unable to retain food. Constipation is now a marked feature. The patient is fairly well nourished, but of late has lost flesh rapidly, though still of fair weight.

A blood examination was made by Dr. Sampson, revealing 4,000,000 reds, 80 per cent hemoglobin and 10,000 whites.

The blood examination was contradictory to a diagnosis of malignancy for abdominal sarcoma or carcinoma is usually accompanied by a rise in the leucocyte count. Cachexia, with lowered red count and hemoglobin percentage was also to be expected if the growth was malignant and of three years duration.

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However, a tentative a diagnosis of sarcoma was made on the general aspects of the case and the abdomen opened for exploratory purposes. malignant liver was found. The lower tumor was not explored. Postmortem examination discovered a large tumor, microscopically carcinomatous, that had arisen from the transverse colon near the splenic flexure, thence sinking into the pelvis, where it pressed upon the sigmoid flexure and rectum. The liver seemed one great mass of carcinomatous tissue. This case serves only to illustrate the importance of systematic observation

of cases, the leaving of no stone unturned in the path of one's search, the consideration in each case of all the evidence to be marshalled from the domains of pathology, chemistry, physiology, hematology from every source whatever. The thousand and one things that thrust themselves forward for consideration in this case I have not time to mention, but not least among these were the blood findings.

In this case they were misleading; perhaps from some temporary vasomotor change, some passing concentration of the blood, some one of the many conditions of which we know nothing as yet, the findings of the hemocytometer were so vitiated as to be only prejudicial, logically, to correct diagnosis; yet, all the hundred conditions that may modify the blood findings, and that must be considered by the diagnostician in his adjudication of a given case, the findings of hematology will often supply him the very firmest premise from which to argue his conclusions.

Of course, every paper is delivered with the accent on its title, but in this instance, let us lay inflection on the necessity of methodical examinations, embracing every means at our command, and let us not fail to appreciate the true economy of being prodigal with time and labor in the making of our diagnosis. It is not the radiograph, the plexor and pleximeter, the thermometer, the microscope, the hematocrit that is indispensable; it is all these. In the making of a diagnosis, we gather together the decimals of chemistry, the infinitisms of microscopy, the truisms of biology and physics and, with our known calories of heat, we compound all this in the tried crucible of experience and sound judgment. This is diagnosis. I have written a "laboratory" paper, but, really, if I were to be asked to name the real essentials of a diagnostic armamentarium, I should say, an eye, an index finger and "horse sense."

PROBLEMS IN MICROSCOPY.

Herbert Lee, M. D., St. Joseph, Mo.

HE use of the microscope has been of great value in promoting the health of the community, and in the science and art of healing,

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since the study of medicine has become a science, resting on the minute microscopical examination of the tissues.

Prior to 1856, when Virchow published his celebrated work on "Cellular Pathology," little was known as to the processes which actually constitute disease. Medical men treated their patients not with any knowledge of the conditions which led up to illness, but merely tried the effects of drugs upon the symptoms that presented themselves without regard to the causes of which the symptoms were the result.

Virchow proved that the cell is the unit of life in the healthy or unhealthy body, and that every cell is the outgrowth of another cell. It was his theory that the most abnormal cellular conditions are the results of injurious agencies at work on normal cells. Others had already progressed considerably in the same direction, among them Schwann, Muller and Paget, but to Virchow must be given the credit for completing the theory and presenting it as a whole; so that it could be grasped by the entire medical world, and become the basis of all medical theory.

The study of bacteriology immediately followed, and although it seemed at first to conflict with Virchow's theory, these two branches of learning were found the one to prove the other's foundation in truth, and out of their teaching afterwards grew modern antiseptic surgery, and the other marvelous developments of present day operative sicence.

The attention of the public is more attracted by the achievements of surgery but it can be shown that Pasteur's perliminary work alone has effected as great a revolution in the study of medicine, for it has placed our knowledge on a sure foundation. The serum treatment of diphtheria, typhoid and tetanus, and the discovery of the cause of malarial fever and its conveyance by the mosquito, are more than moderate achievements, they should rank amongst the triumphs of preventive medicine.

The discoveries of the microscope have also been of untold benefit to the arts and industries of the country.

Agriculture, forestry, horticulture, dairy farming, dyeing, brewing, tanning and many other industries depend for success more and more on a proper knowledge of the micro-organisms which produce those chemical changes commonly known as putrefaction and fermentation. Pasteur showed that

*Read before the St. Joseph, Mo., Medical Society, November 12th, 1902.