The Cleveland Medical Gazette Vol. I. March, 1886. No. 5

The submaxillary gland is of importance not only for its own sake, but because its anatomical connections and situation are such that it can be subjected to physiological experiment, and a number of important results have been reached which I may discuss at some future time.

The results of my work are not only contradictory to the authorities in histology, but also do not harmonize with the requirements of prevailing physiological theories. Bringing this before you does not mean that I ask you to accept either facts or conclusions. I am fully aware of the difficulty of such work, the doubtfulness of the facts and the liability to error in the conclusion. But it is just possible that some of the younger 194members may fare as I did—have not all their time occupied by practice—and if I enlist the interest of any in this most important region I shall feel happy.

A number of years have passed since I undertook this question, and the work on the nerve-endings on muscle, which I had the pleasure to communicate to this society a few months ago, was undertaken more as a study, to make myself familiar with analogous structures, than that I expected to find anything new.

In the investigations on the nerve-endings I used the submaxillary of the half-grown cat, the calf, the ox and the puppy. The method followed was in the main that of Beale. In the case of the cat I injected the whole animal from the aorta with Turnbull’s blue, dissected out the gland, duct, and the nerves entering it. After breaking up the gland into pieces by aid of a needle, from the size of a bean to a pea, I placed it in a dish with a light cover, containing Beale’s carmine (carmine dissolved in ammonia and glycerine). I am in the habit of using a stronger solution than Beale’s. I suspect that the carmine I used in some of these stainings was adulterated with eosin, and that possibly this may have been of advantage. In some of my stainings I used a fluid prepared from cochineal; used ammonia in dissolving the coloring matter, and then added carmine besides. It is of the utmost importance to have no excess of ammonia present, otherwise the staining will be slow and imperfect. I have been staining with this method for years, yet I cannot say why the results differ so much. Some time ago I stained a frog for the nerve-endings in muscle and obtained the most beautiful results, but in the number of stainings I have made since (trying to follow the same method) I have not been by far as successful as then. In breaking up the gland I do not always separate all the pieces, but try to remove the connective tissue holding together the small lobules with the dull end of a needle, and then throw the coherent mass into the stain. In this way I procured a very perfectly injected and beautifully stained submaxillary of a half-grown cat, from which I made a number of valuable specimens. 195The material may remain in the staining fluid for weeks, and may be examined every two or three days to note how the staining is advancing. When the masses stained are large, or the whole gland is subjected to staining, of course the outer parts are more deeply stained than the inner ones, but it is at times convenient to have material of different depths of staining. After the process has continued long enough—the nuclei at least should be very distinctly colored—the material is transferred into a fluid containing glycerine five parts, water and alcohol each two parts, acetic acid one part. Here it may remain about twenty-four hours, and finally it is to be preserved in a similar mixture containing but a trace of acetic acid. I hold acetic acid of varying strength diluted with glycerine in high esteem in such investigation. It does two things, removes the superfluous stain and softens and clears up the connective tissue. Thus treated, the material is ready for examination.

The tissues thus prepared may be hardened in alcohol and sections cut, but this will not aid much in the investigation of the questions that interest us. For this purpose teasing and compression with the cover glass are mainly to be relied upon. It is to be commended to isolate one of the little lobules the gland is composed of, because thus we certainly have ready for examination all the elements making up the gland. The little root which connects the lobule with the rest of the gland will consist of the duct, vessel and nerves supplying the lobule. Such a lobule is broken up with needles and by compression between slides. All these manipulations are to be carried on in glycerine. When the fragments are small enough they are examined with lower powers. The ducts in well injected specimens can be recognized by the rich supply of vessels, the nerve-trunks by the arrangement of the nuclei.

After examining larger fragments with lower powers, smaller ones are selected, subjected to pressure with cover glass, and examined with higher powers. By compression with cover glass, pushing from side to side, one can isolate almost any structure. One can also then make sure whether a fine fibre is 196really in connection with any other structure, or only lying above or beneath the same.

The staining with the carmine will generally not attack the fine nerve fibres. To show these up I have used aniline blue dissolved in water. By these means I have brought out very plainly the nerve fibres, in nerve trunks, of considerable size, as well as those along vessels. I took the material prepared as described, broke up a little piece in fragments of the size of mustard seeds, and left them twelve hours in the blue fluid in a watch glass. Glycerine, if necessary, slightly acidulated, will remove the superfluous stain. I was very much pleased with the action of the aniline blue.

Notwithstanding its physiological importance there is among the authorities as yet no uniformity of opinion on the histology of this gland, save that it belongs to the racemose glands, and is made up of epithelial cells.

The question whether there is present a special membrana propria, enveloping the glandular epithelium, as Pflüger teaches, or a network of partly coalesced connective tissue cells, as Kölliker supposes, may not seem very important, but certainly such points must be cleared up before such questions as to how the nerves end can satisfactorily be answered.

This question, the importance of which will be admitted by all, is also a disputed one. In Stricker’s handbook Pflüger has, in the article on the submaxillary gland, given a detailed account of the mode of nerve-ending in this gland. According to his investigations it is of various kinds.

(1.) The medullary fibre approaches an alveolus penetrates this membrane, the axis cylinder breaks up into innumerable fine fibres, and these pass into the body of the gland cell. (2) Or the nerve passes into a pale cell provided with numerous processes, which in their turn form connections with the secreting cells.

These results of Pflüger have, however, not been accepted by all investigators. Thus Kölliker says on this question:

“The investigations on the nerve-endings in the salivary glands are evidently far from being concluded, nevertheless so much can be gathered from the work done that the nerve fibres 197are in more intimate relations with the glandular elements than has been surmised heretofore. What these relations may be I cannot say, for notwithstanding a very careful investigation of this gland it has not been possible for me to reach views definite and not open to doubt, although frequently enough I have seen fibres and threads of various kinds apparently come in contact with salivary cells. Further, regarding the drawings and descriptions of Pflüger, I must confess, having at the same time nothing but the highest esteem of this investigator, as well as of the care and accuracy he employed in this question, that these do not seem altogether convincing to me.”

I find that the gland cells are enclosed by a membrane (agreeing altogether with Pflüger) which I look upon as decidedly homogeneous (histologically speaking, of course), not showing any structure; by no means being merely a reticulum of connective tissue corpuscles, as Kölliker suggests.

Further: This membrane is provided with nuclei of an oval form (generally), reminding me of the nuclei supplying the nerve sheaths.

Finally: This membrana propria sends out from the alveolar walls, processes, ensheathing—how complete I cannot say—the gland cells. I cannot otherwise explain the glistening lines, which we see in examining sections VI extending from the alveolar wall between the cells, resembling altogether the sections of the alveolar walls. To investigate this matter more accurately, I have stained sections with carmine, also with log-wood, and have found that the alveolar wall and these lines stain the same way. Further breaking up such a section by manipulation with cover-glass, one can obtain fragments of these processes, thus demonstrating that these lines are not merely optical illusions.

The nuclei of this membrana propria are situated on its inner surface and could be distinguished in the gland of the cat, mentioned above, not only by their more oval, oblong or elliptical form, from the more roundish nuclei of the gland cells, but just as plainly by the lighter red or pinkish staining which they 198take on the nuclei of the gland cells being stained a deeper red.

Compressing very small fragments of gland-substance (always of course in glycerine), by means of the cover-glass, beating and pushing it from side to side, thus bursting the alveolus and tearing the membrane and isolating it from the contained gland cells, one can prepare for examination greater or smaller pieces of this membrane. There are by such means obtainable fragments with all sorts of processes and fringes, short and long, many and few, which undoubtedly may remind one of “connective tissue cells.” (See fig. 4.) More convincing than these are membraneous pieces, which may be obtained of various sizes. (See figs. 5, 6.) I have a drawing of such a fragment, which, if enlarged as figs. 1 and 2, would cover over one-quarter of the page, and to which a number of nuclei, more than six, are attached. As a rule, this membrane will, by the manipulations with the cover-glass, not be spread out, but rather folded up, huddled together inclosing some of the gland cells, forming an indescribable nest.

I do not know if it will be necessary to mention in this connection that I consider these nuclei identical with the half-moon cells of Gianuzzi, and cannot help expressing my surprise at the physiological importance assigned to them; for they have been considered playing the role of mother cells, giving origin to glandular epithelium formed to take the place of cells used up in the process of secretion. The dark staining, which in section they seem to assume as well as the semilunar form, will be discussed later. Of course I look upon these nuclei as belonging to flat epithelial cells, as we find them lining nerve sheaths, and serous membranes, and consider them of the same physiological importance as the nuclei of such endothelial cells. A similar ensheathing membrane, or membrana propria, I find in the ducts; but here I have not been able to distinguish processes passing in between the cells. If present they must be exceedingly delicate, for it is not difficult to press out groups of cells from the ducts so that empty pieces (short ones of course) of such can be examined.

While the membrana propria of the ducts can be separated 199rather easily from the inclosed cells, it is different from the surrounding network of capillaries. It seems impossible to remove the capillaries from the duct-walls; while, in the gland-structure proper, among the alveoli, the separation of the capillary from an alveolus, can with little difficulty often be accomplished, so that a piece of capillary can be examined without any other structures lying above or beneath it.

It was somewhat surprising to me, and not a little interesting, to find that the ducts have a decidedly richer blood supply than the gland substance proper, the meshes of the capillaries covering the ducts very closely indeed.

I will also call attention to the fact that, along the terminal portions of the ducts, no arteries or veins can be seen; and what is still more important, no free nerve-fibres can be discovered. Following the ducts outwards, as these attain larger dimensions, and especially where they give off side branches, we find arteries and veins accompanying them, and there will also be found along-side of them fine nerve-branches. So much is certain, that in that region, where arteries and veins are not to be seen, there are also no separate nerve twigs, and that here the union or coalescence of nerve and tissue which the nerves are to influence must have taken place. If one considers the fine meshes of the capillary network enveloping the ducts, and keeps in mind the abundance of nuclei belonging to the capillary, the membrana propria and the duct cells proper, he can imagine how difficult it must be to follow the course of the nerves through and among all these structures. That it has been impossible for me to separate capillary and membrana propria, has been mentioned.

If one were to ask the physiologist: What do you expect us to find in our anatomical investigations on the nerve-endings in the submaxillary gland, he would undoubtedly answer: “You will find an arrangement analogous, if not similar, to that in the striped muscle; the nerve-fibre will be seen to approach the alveolus, penetrate its covering, and the protoplasm of 200the nerve and the gland-cell will be found to come in contact, if not to coalesce.” And that is what has been found by Pflüger.

It has been my endeavor for some time to find something similar to the descriptions of Pflüger, but so far in vain, although many an alveolus has been carefully examined, flattened out and slowly crushed, so that each nucleus could be diagnosed, but never have I found anything which would remind me of the drawings by Pflüger in Stricker’s ‘Histological Handbook.’

In this matter I reasoned thus: If there are any such structures as specialized nerve-endings present in the glandular elements, we might look for an analogy either to the striped muscle fibres or to the capillaries, in both of which nerve-endings are known to be present. In the former case we have the so-called end-plate—the nerve fibre ends in a multi-nucleated mass—but as the muscle fibre, standing for a number of cells, is so different a structure from the gland-cells, we might, with greater probability, expect some such arrangement as we see on the capillaries. Here we see fine fibrils, provided with nuclei, exceeding the fibres two to four times in thickness, entwining the capillary, thus coming in contact with each of the cells composing the capillary wall. In the (submaxillary) gland there are similar structures to be influenced; at least in the capillary as well as in the gland, we have cells lying side by side to be influenced by nerves—hence we might expect similar structures.

Although the books in general have very little to say about the nerve supply of the capillaries, yet it is a fact, and can well be demonstrated, e. g., in the frog’s muscle, that such is the arrangement. As a rule, the fibril cannot so readily be detected, but the nuclei belonging to it are not difficult to recognize. A still more convenient and instructive locality is the base of the frog’s mouth, where everything is one plane, and where the nerve fibres can be followed to their ultimate ramifications.

Let us now see what evidence of nerve-endings we find in or on the alveoli of the gland, examining one, or more accurately, a part of one (the round eminence). We shall see what fig. 1 201presents. We see there two sets of nuclei; one kind oval, longish, stained lighter than the rest, of a pink hue (fig. 1, m), and these a further examination will demonstrate to be the nuclei belonging to the membrana propria, which have also been described before. Besides these nuclei, fewer in number, there is another kind, making up the bulk of the nuclei, more rounded in form (fig. 1, g), and of a deep-red color, which, in their turn, will prove to be the nuclei of the gland-cells; and these two are the only elements or structures that I have been able to demonstrate in a glandular alveolus.

At one time I thought I had found in or on the alveoli the evidence of a network of fine nerves. Quite frequently one can observe longish, even spindle-shaped, often deeply stained, nuclei, which resemble very much those belonging to the fine nerve fibres. (Fig. 2, n, such nuclei are figured.) But so far, whenever I examined such a spindle-shaped nucleus more carefully, I found that it proved to be one of the nuclei belonging to the membrana propria, already described, and the form, as well as its dark color, was due to the fact that it had been examined edgewise. If, by manipulation, such a nucleus was turned over and compressed to present a flat surface, it would have an oval outline and be of a light-red color. Fig. 3 (a, b, c), shows the same nucleus as it appeared when seen edgewise, when seen from the flat and when seen in a position midway between these. Thus is also to be explained the demilune: If the section would strike a nucleus so that it would be seen only edgewise—especially if the membrana propria has a chance to roll up slightly—we should then have a deeply stained body, somewhat half-moon-shaped, the demilunes of the books.

So far, nothing but the nuclei have been mentioned, and the observation might very appropriately be made, that there might exist some exceedingly fine and delicate nerve fibrils without nuclei. Such a system of structures would, of course, be almost impossible to demonstrate with any degree of certainty. I have not, of course, sufficient reason to deny such an arrangement, and would not consider it improbable if we had not, in the capillaries of the frog’s muscle (and other structures) evidence 202certainly not in favor of such an assumption. The fine nerve fibrils supplying the capillaries are richly supplied with nuclei, although the cells which build up the walls of the capillary are by far more insignificant elements than the secreting cells of the gland. Certain it is that as yet there is no evidence of the existence of such fine non-nucleated fibrils, arranged either in the form of a network or a bundle of fine branches.

The examination of the alveoli not leading to any results as to nerve-endings—no structures being discovered there that might be called nervous—I attacked the problem from the other side. I took up the nerve trunks accompanying the ducts, and tried how far I could follow their divisions and branches, and can say that I have spent a great deal of time on this point. In speakings of the bloodvessels, the fact was mentioned that, where arteries and veins of any size run along-side of the duct, these are accompanied by nerve branches, i. e., bundles of nerve fibres, inclosed in a sheath, and these—at least in the cat, the calf and the ox—are made up (excepting, possibly, the very large trunks) of fine nerve fibres. Thicker or medullary nerves I have not been able to discover, even in branches of considerable size, consisting of, say six or eight fibres, and giving off smaller twigs containing one to three fibres. Fig. 7 shows such a nerve-trunk with side branches; neither in the main stem nor in the offshoots are there any medullary nerves discoverable.

If this observation is correct, we see that what has to be traced further, is not the more easily recognized medullary fibre, but exceedingly fine fibrils carrying in certain intervals nuclei, the only distinguishing feature. It will be admitted also (first) that it must be a matter of considerable difficulty to follow such indifferent looking structures, as delicate fibres. And (secondly), one cannot expect to find medullary nerves approach the alveoli, penetrate the membrane, come in connection with the secretory cells, etc., etc, as has been done by Pflüger. If the question should be asked how far I have been able to follow these nerves, I should say: Small twigs consisting of one to three fine fibrils, enclosed in a sheath 203branch off from a trunk, not much larger, and apply themselves to the membrana propria of the duct; their sheaths in all probability coalescing with that membrane. Here they have been seen to apply themselves to some bloodvessel and are now lost out of sight, being hid by all the many structures mentioned above, the nuclei of membrane, capillary, duct cells, and the fibre cannot so readily be distinguished from the membrana propria of the duct upon which it rests. But I do not wish to be understood that because the nerves have been lost out of sight, along-side of vessels, that they have their “ending” there, inasmuch as the network of bloodvessels is such a close one that the nerves cannot but help coming in contact with them. Fig. 8 shows such a fine nerve-trunk. By the aid of aniline blue the fine fibrils have been made quite plain. Such fine fibrils can by the same means be demonstrated in much larger trunks, as shown in fig. 7, and it can be shown that even such large trunks consist of nothing but these fine fibrils.

I have also seen, exceptionally however, fine nerve twigs run into the alveoli directly, but the nerves here were of the same nature as the ones described going to the duct. Fig. 9 shows a fine fibril passing on to an alveolus and running probably on to a vessel; the nerve fibre resting upon gland cells, also stained, could not with absolute certainty be traced to the vessel. There is a small break shown in the drawing.

As intimated, especially if the cells of the duct are still in situ, it is impossible to follow the fine nerve-fibres any further. By pressing out the cells from the ducts, one can obtain portion of the duct, with the capillaries belonging to them, but they are short pieces, and the nerve fibril is not easily discoverable.

But there remains one fact to be mentioned, which may throw light on the question, as to how the nerves end and which in my opinion might and does clear up the difficulty.

Examining the capillaries supplying the gland alveoli, one is able to find nuclei, not belonging to the capillaries themselves. This statement can be made for two reasons. In the first place, the majority of these nuclei have not the form 204of the nuclei of the capillary, and in the second place these nuclei are situated on the outside of the capillary wall. Whoever has examined the capillaries of the frog’s muscle knows that just such or the same nuclei belong to nerve-fibres, supplying the capillary wall. In the mammal of course these nuclei are smaller and not so conspicuous, nor can we procure pieces of capilliary of any length (the structures under examination here, not being in one plane.) Thus we cannot expect to have matters so plain here and easy of demonstration. After finding these nuclei, it was of course my desire to find if they were united by fibres. It must in this matter be kept in mind, that if there are such fibres present to which these nuclei belong, these may be expected to be in the most intimate relation with the capilliary wall, if one is to influence the other—and therefore not of ready and easy demonstration.

I have, however, succeeded in showing in a number of instances that such fibres exist. Figs. 10 and 11 show such a fibre uniting several nuclei. The shortness of these fragments makes a more perfect demonstration almost impossible.

If this observation is correct, we find on the capillaries the same (only finer) fibres provided with nuclei, which we have lost out of sight following the branching out of the nerves.

There is also some evidence of fine fibres in the membrana propria of the ducts, inasmuch as we find here nuclei along-side of the capillaries, these not being the nuclei of the membrane, but resembling altogether the nuclei of the nerve fibres.

Again, as stated above, I have not been able to find any such evidence of nerves in connection with the gland cells themselves. In case, however, such an arrangement or something similar existed, why should it have been impossible for me to find evidences of such as well here on the gland cells as on the capillaries; and should they not be more readily found in the gland than in the capillary, inasmuch as we have larger structures to deal with here in the gland.

The conclusion then regarding the nerve-endings to which my work has led me are these:

There were no special nerve-endings found in connection with the gland cells themselves. We find, however, upon the 205capillaries evidence of the same kind of fine nucleated fibrils, which we find to be present in the fine nerve twigs, as far as we can follow them in their course towards their final distribution. To explain the action of nerves on the process of secretion we would have to assume either that the nerves accompanying the capillaries also influence the gland cells, or that the glands are stimulated to activity by some changes in the condition of the capillary wall furnishing a greater amount of oxygen and nutritive fluids.

The results are partly negative, partly positive. The latter I wish to emphasize, believing it worthy of attention, as it may throw light on the physiology of the capillary wall, which seems to be altogether too much neglected. The negative I have offered, knowing well enough that such negative results must be accepted as final with much hesitation.

To any one feeling inclined to undertake investigation on this gland, I would make a few suggestions:

(1) Make sections through gland hardened in bichromate of potash, or alcohol, and stain with staining fluids.

(2) Compare in material prepared as above described, the vascular supply of duct and gland substance proper.

(3) Compare gland and duct cells.

(4) Find the nuclei of the membrana propria and compare the same with the nuclei of the gland cells.

(5) See if you can examine the same nucleus from different sides. Do you think that the demilune of books and the nucleus of the membrana propria might be the same thing?

(6) Prepare pieces of the membrana propria covering the alveoli. What is your opinion—is there a membrane or only a reticulum of connective tissue cells?

(7) Prepare pieces of membrana propria of duct.

(8) Can you find the nuclei of the duct, and other nuclei on the exterior of the capillaries?

(9) Can you find pieces of capillaries belonging to the alveoli, and do you find any nuclei on them?

(10) Examine the wall of the duct in injected and uninjected material, both stained.

(11) Follow the bloodvessels—can you find nerves on the walls of arteries?

(12) Of what structure do you find the root of a little lobule to consist?

(13) How do the nerve trunks differ from the fibrous envelope holding together all these structures?

(14) Differentiate between the nuclei of the nerve fibres and the nuclei of the nerve sheath.

(15) Examine nerve branches of various thicknesses—what do you find the nature of the nerve fibres to be? Do not forget the aniline blue and try other staining fluids.

(16) Can you find evidence in the alveoli of other structures besides capillary, membrana propria and salivary cells?

(17) How far have you succeeded in following the fine nerve twigs?

206(18) By all means try different methods, different tissue, and compare the results. See what you can discover by simply teasing material treated with Muller’s fluid, and other stained and treated as I have described.

(19) Follow the course of the arteries, and note where the larger vessels pass into the capillaries.

But the contributions to medicine of all his predecessors dwarf into insignificance when compared to those of Galen—who lived and wrote in the middle of the second century—and whose writings were ultimate authority, until they were attacked and publicly burned in the 16th century by the arch-quack Paracelsus. Galen, although born in Pergamus, in Mysia and living there, was called by the Emperors M. Aurelius, and L. Verus to attend them in the northeastern frontier of Italy, and was for a considerable period of time physician to the emperor, spending a considerable portion of the last half of his life at Rome. He died in Sicily in 201 aet 71 (?) There are ascribed to him 83 treatises on medicine about which there is no question as to their genuineness, 19 that are questionable, 45 undoubtedly spurious, 19 fragments, 15 commentaries on Hippocrates’ works. Besides these, he wrote a great number of works (not all on medicine) whose titles only are preserved, so that altogether it is believed that the number of distinct treatises cannot have been less than 500. These were, on (1) Anatomy and Physiology, (2) Dietetics and Hygiene, (3) Pathology, (4) Semiology and Diagnosis, (5) Materia Medica and Pharmacy, (6) Therapeutics including Surgery, (7) Commentaries on Hippocrates, (8) Philosophical and Miscellaneous. Most of these works are still extant in Greek (in which they were originally written). They have been translated into many modern languages. His works on anatomy and physiology are most valuable. 207But it is not certain that he ever dissected human bodies. His knowledge he derived from dissecting apes, bears, goats, etc., and his knowledge of physiology from experiments on these animals. His pathology was speculative.

In diagnosis and prognosis he laid great stress upon the pulse, on which subject he may be considered as the first and greatest authority, for subsequent writers adopted his system without alteration. He placed great confidence in the doctrine of “critical days,” which he believed to be influenced by the moon.

In materia medica he was not considered as good authority as Dioscorides. He was prone to making prescriptions containing many ingredients, some of which were entirely inert. He seems to have placed more faith in amulets than in medicine, and is supposed to be the author of the anodyne necklace, which was for a long time famous in England. He was an allopathist in his notions, i. e., he believed that disease is something contrary to nature, and is to be overcome by that which is contrary to the disease itself. At the same time he taught that nature is to be preserved by that which has relations to nature, in accord. Hence his two indications, “Overcome Disease,” “Sustain Nature.”

Before this time, as already intimated, the medical profession was divided into several sects, who were always disputing with one another. After him, all these sects seem to have merged into his followers. The subsequent Greek and Roman medical writers were compilers from his writings, and being translated into Arabic, Galen’s works became authority in the East as well as in Europe, and continued to be so for fourteen hundred years. In 1559, Dr. Geynes was cited before the college of physicians for impugning the infallibility of Galen. On his acknowledgment of his error and humble recantation, signed with his own hand, he was received into the college.

The great mass of Galen’s works, together with modern improvements and researches, have now in great measure consigned them to neglect, but his fame can only perish with the science itself. As in the case of Hippocrates, his immeasurable 208superiority over his contemporaries seems to have acted as a check to all attempts at further improvement.

The first names of any renown that occur subsequent to Galen are those of Oribasius, Alexander of Tralles, Ætius and Paulus Egineta, who flourished between the fourth and seventh centuries. They were all jealous Galenists, and those of their writings which are still extant are, for the most part, compilations from the predecessors, especially from their great master, Galen.

The writings of Paulus seem to be the last of any written in the Greek language, which had been the language of medical science for more than a thousand years. At about this time the Arabian school was beginning to rise into notice. The earliest Arabian writers on medicine of whom we have any notice or certain account, is Ahrum, who was contemporary with Paulus. The most celebrated physicians of this school were Rhazes, (who flourished in the ninth century, and was the first to describe small-pox) and Avicenna who flourished early in the eleventh century, and whose ‘Canon Medicina’ may be regarded as a cyclopaedia of all that was known of medicine at that time (as well as collateral sciences). This was a compilation from Greek writers, whose writings had been translated into Arabic, (for Avicenna was not a Greek scholar himself). Avenzoar, and Averrhoes flourished in the twelfth century. The last was a celebrated philosopher as well as physician. The works of Hippocrates and Galen, which, together with the works of Aristotle, Plato and Euclid, were translated into Arabic in the ninth century, formed the basis of their medical knowledge; but the Arabian physicians did good service to medicine, introducing new articles from the East into European materia medica, as for example, rhubarb, cassia, senna, camphor, and in making known what may be termed the first elements of pharmaceutical chemistry, such as a knowledge of distillation, and of the means of obtaining various metallic oxides and salts.

Upon the decline of the Saracenic universities in Spain, which was about the time of the death of Averrhoes, the only medical knowledge that remained was to be found in Italy, where the School of Salerno acquired considerable celebrity, which it maintained 209for some time, till it was gradually eclipsed by the rising fame of other medical schools at Bologna—where Mondino or Mundinus de Leozza publicly dissected two human bodies in 1315.

Contemporary with Mondini, lived Gilbert, the first English writer on medicine who acquired any repute; and the next century gave birth to Linacre, who after studying at Oxford spent a considerable time at Bologna, Florence, Rome, Venice and Padua, and subsequently became the founder of the London College of Physicians. It was in this fifteenth century that the sect of chemical physicians arose, who claimed that all the phenomena of the living body could be explained by the same chemical laws as those that rule inorganic matters. Although the illustrations and proofs which they adduced were completely unsatisfactory, yet the tendency at the present time is in the same direction, since chemistry and physiology are better known.

This seems to be a period prolific of new diseases. In the thirteenth, fourteenth and fifteenth centuries we hear most of leprosy, and of the visitation of the plague in Europe. Whooping-cough and scurvy were never described by any writer anterior to the fifteenth century. Syphilis was first recognized in Italy in the fifteenth century, from which country it spread rapidly over the whole of Europe.

In the sixteenth century the study of human anatomy may be said to have been fairly established by the zeal and labors of Vesalius, and in this and the succeeding centuries we meet with the names of many physicians whose anatomical and physiological investigations tended either directly or indirectly to advance the science of medicine. This was the epoch of Eustachius, Fallopius, Asellius, Harvey, Rudbeck, Bartholini, Malpighi, Glisson, Sylvius, Willis, Bellini, etc., names preserved in anatomy.

Chemistry was now being separated from alchemy, and advancing to a science, and a combination formed between its principles and those of physiology, which gave rise to a new sect of chemical physicians, quite distinct from the sect represented two centuries before by Paracelsus. The chemical 210school was succeeded by the mathematical school, of which Borelli, Sauvages, Heill, Jurin, Mead and Freind were amongst the most celebrated. While at the same time the old Galenists were fast disappearing. To the rival sects of this period must be added the Vitalists, which originated with Von Helmont, and with some modifications was adopted by Stahl and Hoffman. The greatest physician of the seventeenth century was, however, Sydenham, who, though inclining to the chemical school, did not allow his speculative opinions regarding the nature of disease to interfere with a careful consideration of the indications for treatment, as derived from the symptoms, and from experience.

Boerhaave, a Dutch physician and philosopher, occupied special prominence in last part of the seventeenth and the early part of the eighteenth centuries. He engaged in the practice of medicine at Leyden in 1693, and became professor of theory and practice of medicine in the university of that city in 1701. He was erudite, exact, simple and eloquent, and hence as a lecturer very popular. He specially advocated simplicity in practice of medicine. Professor of botany was added to his duties in 1709. He wrote a treatise in 1703 (in Latin) advocating mechanical and chemical hypotheses in medicine. In 1708 his institutes of medicine extended his reputation; and in 1709 appeared his famous ‘Aphorisms’ on the diagnosis and cure of disease. In this was a well defined classification of diseases, including their causes, nature and treatment, which was adopted by his contemporaries. He was distinguished as a botanist and chemist. He published a description of plants at Leyden in 1710, and became professor of chemistry in 1718 in addition to his other duties. He made chemistry popular by presenting it in a clear and attractive style, in his lectures and in his ‘Elements of Chemistry’ (1724).

On account of his attack of gout he was constrained to give up the teaching of botany and chemistry in 1727. He was elected a Fellow of the Royal Society of London in 1730. His fame extended over the world. A Chinese mandarin hearing of his fame addressed a letter to Boerhaave, physician in Europe, which reached him in due time. His practice was 211lucrative, and he spent money freely in the interest of science and benevolence, yet such was his success that it is said that at his death (in 1738) he left an estate of nearly a million dollars.

Cullen, who was born in 1710 and died in 1790, was undoubtedly the greatest medical man of his age. It is especially interesting to read the biographies of such men as Cullen and of Hunter his contemporary, and of Jenner of the last half of the eighteenth century, and of John Brown the quack—though much quoted.

The present century may be considered as the epoch of physiological experiment and clinical observation. The efficient laborers of the last eighty years in the field of medicine have been so numerous that it would be impossible to notice at this time even those deemed most celebrated, while it would be invidious to attempt such a selection.

In this time our materia medica has received a large number of most important additions, amongst which may be noticed, morphia, quinia, strychnia, iodine and the iodides, bromides, cyanohydric acid, cod-liver oil, chloroform, chloral, nitrite, amyl and a long list of preparations from the vegetable kingdom and from the hydrocarbon series.

The physical diagnosis of disease has been facilitated to an extent far beyond what the most sanguine physician of the last century could have deemed possible, by the discovery and practical application of the stethoscope, the pleximeter, the speculum in various forms, the ophthalmoscope, the laryngoscope and the thermometer; while chemistry and the microscopy have been applied successfully to the investigation of the various excretions, and especially of the urine, bile, and in the study of digestion where the process could be observed in its various stages in the person of Alexis St. Martin.

But the field for the medical historian broadens immensely and can best be appreciated by study of a catalogue of medical books and periodicals of the present century.

On the fourth day of June I was called to see Miss C. R., aged nineteen years, a clerk, who told me that she had gone to bed the night before perfectly well, and that when she awoke in the morning she found herself totally blind, and had remained so up to the time of my visit, about eleven o’clock. This blindness she said had come on without the least pain or bad feeling, and the eyes were not in the least degree uncomfortable, nor had they been during the morning. No cause on the part of the patient could be assigned for the attack, and nothing of the kind had ever happened to any member of the family before. The external examination gave not the slightest evidence of any disease of the eyeballs or lids. The conjunctiva was perfectly normal, as were also the cornea iris and pupil. The ophthalmoscope revealed a perfectly healthy retina and optic nerve and clear media. The tension of the eyeball was normal. There was not the least constitutional disturbance, if we except a marked nervousness caused by the fear that she would be permanently blind. The patient declared most positively that she could not see the lamp even when held close to the eyes. From the fact that the pupils were perfectly normal and moveable under the influence of light, and that the patient put out her hand to shake hands with me in a way that I felt she could not do if she did not see, I diagnosed a case of hysterical blindness. It was more than a simulated blindness, for all the anxiety and mental distress of actual blindness were present; and I am satisfied the patient was honest in her belief that she could not see. The ordinary remedies for hysteria were given and were taken faithfully and regularly, and although for several days she took large doses of the bromide, valerianate of ammonia, hyoscyamus, assafœtida, and kindred drugs, there was not the slightest improvement in her vision. These remedies were continued from the fourth to the fourteenth without any perceptible effect. After ten days I began to give her 213tonics instead, and although she took the elixir cinchona with dilute hydrochloric acid, tincture of nux vomica, quinine, iron oxid of zinc, and finally stimulants, there was no improvement and the patient said she remained in total darkness. This tonic course was continued up to the twenty-ninth, and had been followed out thoroughly for two full weeks without effect.

During the nearly four weeks treatment the patient said that when the eyes were shut she could discern the position of the lighted lamp, but when the eyes were open she could not see the lamp or the slightest object, or even tell daylight from darkness. At various intervals during this time her pastor visited her and offered her his most heartfelt sympathy. Her friends were becoming exceedingly anxious least the sight would never return, although I could assure them that there was not the least danger of permanent blindness. I became satisfied at this time that medication was not going to dispel this peculiar attack of hysteria and that it would need something besides medicine to produce such an impression upon her mind that she could overcome it, so I told her that I was going to do something the next day that would surely make her see before night, and that she should be of good cheer for her sight would return very soon. The next morning I went down about nine o’clock armed with my ophthalmoscope, my case of trial glasses and my Hearteloup’s artificial leech. The patient seemed to be quite confident that she would soon see, and was very hopeful as to the result of what was to be done. I looked into the eyes with my ophthalmoscope, and then applied the cylinder of the artificial leech to the temples without scarifying and used considerable traction, first on one side and then on the other, having previously told her not to open the eyes until I told her to do so. In about half an hour I told her to open the eyes gradually so as not to let the light in too suddenly and then tell me what she could see. The instant she opened them she said I can see the light and the position of the window. I then told her to close the eyes again and I reapplied the cylinder and commenced the suction as before. By this time the temples had become red and so sensitive that she now complained of some pain when the cylinder was reapplied. After twenty minutes 214she was told to open the eyes again and she said she could see objects about the room distinctly. She was then tried with large letters but she said she could not see to read them, but could see the black objects. Told her glasses would help her and placed a No. 72 convex spherical glass before the eyes when she could see Jaeger No. 20, then told her she needed other glasses and replaced the No. 72. She now saw to read No. 16. I continued taking off and putting on this same No. 72, with good effect and whenever she came to a standstill in reading reapplied the cylinder with uniform benefit until finally after two hours constant work she could read Jaeger No. 1. During all this day she was able to see distinctly. The next day she was again unable to read but a short repetition of the same course brought her vision back again. There was no return of the blindness after that except occasionally for a short time at intervals of two or three days.

In the course of ten days all trace of the difficulty had passed by and since has never returned. This case was diagnosed as one of genuine hysteria and not one of simulating blindness or malingering, and is reported as the most marked case I have ever had illustrating the effect of hokus pokusing (to call it by a mild name) which produced such a strong mental impression that the patient lost sight of her own peculiar mental condition, and by which a perfect cure was effected.

To her the blindness was real, and her friends feel that a remarkable cure has been performed. Such a blindness can occur in any nervous hysterical patient, while simulated blindness usually occurs in those who wish to avoid service in the army or navy, or in the case of lazy young people who do not wish to study at school or college, and in those who have received a slight injury and wish to make it appear more serious for the sake of obtaining large damages, either from private individuals or corporations.

For its detection there are several methods which are usually sufficient to give us positive proof that the blindness is not real. Von Graefe placed a number eight or ten prism in front of the eye, with the base upwards, downwards or sidewise, and 215if strabismus is present before the removal of the prism there is binocular vision.

Juler places spectacles with an opaque glass in front of the good eye, when, if the patient can read, he must see with both eyes; or he places concave 20 before the good eye, when if the patient can read fine print he must see it with the other eye.

Juval places a ruler before the eye so as to cover part of the page to be read, when, if one eye is blind, not all the page can be read.

Mittendorf puts atropine in the good eye, when if the patient can read fine print he is not blind with the other eye.

Wells places a prism in front of the supposed blind eye, and notices whether the apis of vision of that eye changes when the prism is removed.

Bull bandages the good eye and places a prism in front of the other eye, and holds a lighted candle before the eye, and if the eye turns as the prism is turned, the eye is not blind.

The test with Snellens or other colored letters is also a good one. A word with alternate red and bluish green letters is painted on glass and placed in the window, and the patient is asked to read the letters. If a bluish green glass is held in front of the good eye, he will see only the green letters unless he can see with the other eye, for all but the red rays in the red letters are cut off in the transparency in the window, and the green glass cuts the red off, leaving those letters a perfect blank to the well eye.

Kugel places various colored glasses before each eye and then places an opaque glass in front of the sound eye, and a transparent glass of the same color before the other one, and if the patient sees the object, he is simulating blindness.

Herring has the patient look through a tube large enough to cover both eyes, and then suspends a small ball in front of the tube and drops small objects near this ball, and if the patient can tell whether the balls are dropped in front of or behind the suspended ball, he must see with both eyes.

Lawrence recommends the stereoscope for detecting binocular vision, and places in a covered stereoscope a picture each 216side of which is different, and yet such as to make a single picture when both sides are seen. A clock dial, for example, with figures in one side only or figures with complemental colors, such that with both eyes the object would appear differently colored from what it would when seen with either eye separately. The distance apart of two objects held up in front of both eyes can be readily told by the patient if he sees with both eyes, no matter how the objects are held with relation to each other. But if there is vision with one eye only, the patient can tell the distant apart with accuracy only when the objects are both held at the same distance from the eye, but not when one is held considerably in front of the other.

One who sees with one eye only always thinks he is nearer to the object than he really is when reaching out for that object. It is always more difficult for him to pour from a pitcher into a cup or glass if held a little distance below it, hence the blind in one eye usually place the nose of the pitcher in contact with the glass before pouring. The old parlor trick of placing two pins in the wall and putting a cent on them and directing the patient to stand across the room and then walk over to the cent and knock it off with the outstretched finger without hitting the pins, may be made use of as a test in simulated blindness, for with one eye the patient always falls short of the mark the first time the experiment is tried. The most simple method of detecting simulated blindness in one eye is by noticing the movement of the pupil under the influence of light. If an eye is blind, the light has little or no effect upon it when the other eye is closed. The pupil is usually dilated. It may be well to mention here that atropine dilatation is generally wider than that due to amaurosis, and also that a cone of light from a strong convex glass thrown upon the sound eye will contract the pupil of the blind eye if the dilatation is not due to atropine. Simulated blindness in both eyes is not likely to be seen, and then the condition of the pupil is of great value in detecting it, and is one of the best guides in connection with the ophthalmoscopic observation.

Miss H. E., aged 20, American of Irish parentage: dark brunette, short in stature but apparently quite handsomely formed, and ruddy with health. She has never been sick in her life. Has menstruated normally since her fifteenth year, though scantily during the past year. She feared she had been injured a few days previously by the overturning of a chair upon which she was standing, as she had since felt pain and uneasiness in the lower pelvic and pubic region, for which she sought advice.

Upon examination I found no injury worthy of record, but the malformation here described. Cases of this anomaly have been recorded from time to time, being always of interest to the teratologist, occasionally requiring attention on account of interference with the marital relation or parturition, and being referred to in every discussion on superfœtation.

The external genitalia are well developed. No hymen, nor any remains of one. I have no reason to doubt her virginity. An inch within the introitus vaginæ the finger met a narrowing into which only its tip would pass. Searching to the left another smaller opening was discovered, the two being separated by a strong membrane. Returning to the right or larger passage, was able by careful dilatation for ten or fifteen minutes to insert three-fourths of the length of the index finger and encounter another narrowing, which being patiently overcome, the first joint of the finger found more room and examined uterine cervix and the external os, which is linear antero posteriorly. The neck projects about half an inch into the vagina. The lips are thin, of normal density. Withdrawing the finger and finding the smaller opening, could succeed in penetrating only about an inch. Observed a third, smallest opening in the left vaginal wall, between the ostium vaginæ and the second opening described.

The patient would consent to no interference that could possibly cause even temporary disability for daily housework and care of an invalid mother, but agreed to return daily for a few days. After dilating without anæsthesia fifteen to twenty minutes daily for four days, could pass two fingers or a Fergusson speculum one and one-eighth inches into the right passage, and could pass one finger readily, or speculum seven-eighths of an inch in diameter into the left passage. The septum between the two passages is placed antero posteriorly. It is about an eighth of an inch thick, and has the appearance of any other portion of the vaginal wall. It begins an inch within the introitus, and extends 219to the uterus, making a right and left vagina of normal length. The third, smallest passage, admits a sound and extends upward an inch in the left lateral vaginal wall and ends in a blind extremity.

The right vagina discloses an uterine os three-eighths inch in length antero posteriorly, the anterior end of the slit inclined toward the median line. The sound passes readily a distance of one and three-eighths inches, entering in a direction upward and inward half that length, and then turning upward and outward. The sound moves freely in the cavity, and the lining membrane evidently contains folds. Secretion of the cervix free.

On the left side the os uteri is smaller, the opening not exceeding a quarter inch, the length being laterally. The lips are in a pouting shape, the anterior, especially, having quite a fold above it. The sound enters freely nearly an inch in a direction upward, outward and slightly backward; lining membrane apparently folded. Very little secretion. By introducing two fingers of the left hand, palm upward, the index into the right vagina and the second finger into the left, the two uterine mouths can be examined simultaneously, and this gives a very vivid impression of the condition. As to the shape of the whole uterus very little can be determined by bimanual examination, the vaginal walls being so tense and abdominal thick. By the rectum the uterus can be felt flat and wide, but no bi-lobing is apparent.

The young lady could not be persuaded to permit an examination during menstruation to determine whether the flow took place on both sides.

Though at best societies in their present form are not very old, medical associations, differing somewhat in their organization 220and aim, are as old as the science of medicine itself. Even in the fabulous ages it had its heroes, and some rose to the height of deification. In earlier ages those who practiced medicine were looked upon as inspired. They, in addition to belonging to a profession, constituted a class or caste. In some Asiatic nations, and among some of our Indian tribes, it is very much the same at present.

One must belong to the caste, or be able to trace his descent from it, as a necessary qualification to practice medicine.

This is the earliest form of a medical society, and though it may not possess many progressive elements, it has elements of strength.

What few investigations it did make, it kept. Its peculiar organization and position fitted it for being a good conservator; and when the star of empire took its western course, the tide of medical knowledge stored up and held sacred and secret in Asia, Egypt and Greece, flowed out and was diffused over five continents.

Hippocrates, about twenty-five hundred years ago, took the light from under a bushel. About three hundred years later the great Alexandrian school or society—for it was a society as well as a school—trimmed the light and set it higher, but it was so obscured and encompassed with exclusiveness and secrecy as to be a long time in reaching the masses.

The first societies in Germany, France and Great Britain were in connection with their institutions of learning, as they were at an earlier period in Egypt and Greece. In Rome we have reason to believe that they were more independent, as the physicians used a society seal as a label for their medicine. Truly independent society organization and work is comparatively of our own day. Even in the early part of the present century, British authority was the London, Edinburgh and Dublin colleges.

In our own country, previous to the organization of the American Medical Association, about thirty-six years ago, there was very little system in society work. That organization marks a new era in society usefulness. From it sprung the International Medical Congress, making a unit of medical 221investigation and progress of the world. We point with pride to Philadelphia as the city in which the association was organized, and to the able and determined stand our State has ever taken in sustaining and strengthening it. It has been a power for good to American medicine. It has elevated and is elevating the standard of our American medical colleges.

The progress in society organization, work and usefulness in the last thirty-six years is greater than in all American medical history previous to that time. We had then a few isolated independent medical societies without unity and without influence. We have at present a society in almost every county, a State society in every State, all united in an association and wielding an influence national and world wide.

Great as the benefit has been to the profession at large, it has been greater still to the individual practitioner. It has been to him a post-graduate school.

In our societies A. meets B., B., C. and C., D. They compare their investigations, experiences and theories, and each is benefited.

Our society enables us to know one another better. It is a true saying that, “no man is as good as his best deed nor as bad as his worst.” Our meeting in society aids us in striking the balance and makes us more united, by forming and cementing friendships. They discourage quackery, empiricism and everything that is professionally low and mean. They encourage and stimulate purity, nobility and rectitude. They are a strength to us medically and medico-legally. All that is necessary on our part to secure us these benefits and many more which might be enumerated, is to do our duty to our county, State and national societies. I will now present to you what I believe to constitute at least part of that duty.

First. Punctuality and regularity in attendance. This increases our interest and gives the society strength.

Second. Support with our intellect. We may not all have an equal number of talents, but he that has five should use them, and he that has one should use it, and the use of that one may be just what the society needs at the time.

222If we have anything we think good in theory or practice, or any interesting case, let us report to our society.

I believe everything presented should be in writing, for very few physicians are good extemporaneous speakers, and all members should have such notice of the subject of all papers to be read before the society as will give them time to prepare for intelligent discussion; for unless a man has a clear idea of his subject he is liable to wander off into a labyrinth of side issues.

When appointed for a paper, we should have it ready and be on hand to read it. We should have more papers published, and to better prepare them for publication, each society should have an editor and a publication committee, with ability and power to revise, correct and publish papers and reports of the society.

Third. We should support our society with our influence. All have an influence, and there is no neutral ground. It must be for or against.

Never was there a time when there was more need of the support of the good men in the profession. The code of medical ethics has been attacked. The American Medical association has been attacked.

An attempt has been made to make the one obnoxious and destroy the harmony and usefulness of the other.

Fourth. We should be prompt in paying our dues and all other necessary demands that may be made on us by our society. Negligence—for it is seldom or never inability—on our part may not only embarrass the society, but tend to destroy our interest in it.

I have a great regard for the Venango County Medical Society. It was the first society I joined after graduating, over twenty years ago, and I have always highly prized the friendships herein formed.

Death has taken some from us, good men and true, but I am pleased to see that we are also adding to our number so many young men, and growing in strength. Let us each do our part to keep up this growth, so that when we are weighed in the balance we may not be found wanting.

I thank you for your kind aid and forbearance throughout the year. May our society live long and prosper.

A. R. BAKER, M. D., Editor.

S. W. KELLEY, M. D., Associate Editor.

One of the old land marks of the medical profession is gone! Few men are privileged to continue in actual practice fifty-seven years! Thousands have heard him lecture, seen him operate and read his published papers. He was indeed a remarkable man. At the age of eighty he continued to operate with the freshness of youth. As a lecturer he was terse—direct to the point; as a writer he was lucid and clear; as an operator he was steady, bold and self-reliant; as a man he was a Christian.

If there was one thing more than another more prominent in his well-rounded character, it was his devotion to duty. He was a man of fine religious faith, devout in his behavior and an excellent theologian and Biblical scholar. The two things he is said to have most enjoyed were a surgical operation and a prayer meeting. He was a consistent member of the Presbyterian church, and his example of earnest, unselfish devotion to 224duty can not help but leave an influence for good which will last long after his brilliant surgical operations are forgotten.

Dr. Post was born in New York city in 1805, graduated from Columbia College in 1822, became a medical student in the office of Dr. Wright Post, his uncle, an eminent surgeon of a former generation. He graduated from the College of Physicians and Surgeons in 1827. After spending two years in the medical schools and hospitals of Paris, Berlin and Edinburgh, he commenced active practice of his profession in New York city, which he continued until the week before his death. He was one of the founders of the Medical Department of the University of New York, taking the chair of surgery and pathological anatomy, and at the time of his death was president of the medical faculty and emeritus professor of the clinical surgery in that institution. His funeral took place Wednesday, February 10, and the Church of the Covenant, of which Dr. Post was a member, was crowded with professional and other friends of the dead man.

The annual meeting of the Alumni Association will be held at 2 o’clock, P. M., Wednesday, March 3, in the amphitheatre of the City Hospital corner of Erie and Lake streets.

Dr. E. D. Burton of Collamer, Ohio, will be the orator of the occasion, and Prof. Proctor Thayer, the elected poet.

The president, Prof. G. C. E. Weber, will also deliver an address.

The subjects for discussion are: First, Cholera, the leading speakers being Doctors Thayer, Lowman and Kelley. Second, Diphtheria, its Aetiology and Treatment, with Dr. Knowlton of Brecksville, and Dr. Orwig of Cleveland, as leading speakers. The annual election of officers will be held, and other important business transacted.

225The Hon. S. E. Williamson will deliver an address to the graduating class in the evening. The graduating exercises will be held in the First Methodist Church, corner of Euclid avenue and Erie street. There will afterwards be a reception and banquet at the Hollenden.

The Western Pennsylvania Medical College has been organized and liberally endowed, and will soon assume possession of its new building on Sixth street, Pittsburgh, Pennsylvania. The course of lectures will not begin, however, until October. The faculty will be composed of the following well-known, earnest and hard-working practitioners: Professor of Anatomy, Dr. Heckelman; Professor of Physiology, Dr. Allen; Professor of the Principles of Surgery, Dr. Murdock; Professor of the Practice of Surgery, Dr. McCann; Professor of the Principles of Medicine, Dr. Shively; Professor of Clinical Medicine, Dr. Lane; Professor of Chemistry, Dr. Blank; Professor of Materia Medica, Dr. Gallagher; Professor of Obstetrics, Dr. Duff; Professor of Gynæcology, Dr. Asdale; Lecturer on Dermatology, Dr. Dunn; Lecturer on Nervous Diseases, Dr. Ayers; Lecturer on Orthopædic Surgery, Dr. King; Lecturer on Genito-Urinary Diseases, Dr. Thomas.

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