sumed charge, he has begun to carry out his plans. The first has been the establishment of a new laboratory, separate from the ordinary clinical laboratory where urine, blood, sputum, etc., are examined.

This new laboratory is located on the top floor of one of the old buildings of the Charite. The second floor is occupied by the animals and supplies. The laboratory covers four rooms and a large hall passage. The wards containing the patients allotted to the first medical clinic are in a separate building not far distant.

One thing which is unique in connection with the new laboratory is the animal operating room. This room which is painted white, really would do credit to a small hospital. It is a small room having good light, and fitted with a steel animal operating table, automatic, by which animals may be placed in any position. About the room are tables and cabinets with a variety of surgical instruments, machines and appliances, for work on animals. In such a room, asepsis may be carried out in animal operations.

The bacteriology room is rather large. It is fitted up for carrying out experiments with micro-organisms and for serum work. Here small amounts of culture media can be made. Of special interest are large cabinets with sliding glass doors, where culture media and glassware of all kinds are stored ready for use. In similar cabinets glassware not sterile is kept. In the center of the room a wide table is built which contains drawers on both sides from the floor up. The top of this table is of slate in contrast to the work table around the wall, which is covered with glass. At each end of this large table are sinks.

The autoclaves and the incubator are each large and first class. Of no little moment is the fact that the stools to sit on are white enamel, steel revolving, and can be elevated or iowered.

For chemical work there are two large rooms. One room resembles an ordinary chemical lab oratory with the exception that here and there is seen some costly article of furniture. Fine sinks, hoods, and apparatus for carrying out extensive experiments are present. The second, floor is also fitted up as a work room. Delicate balances, electrical apparatus, freezing appar atus, baths at constant temperature, and cabinets of chemicals are kept here. In the hall outside are large wardrobes where chemicals are kept; and the men working on problems in chemistry have large cabinets here where they keep bodies or compounds which they have made.

In the hall the ice chests are placed. One is an ordinary large ice chest and one side is used for the bacteriology and serum diagnosis,

the other side for chemistry. The second ice chest is known as the "Frigo" chest. It is a large chest with thick walls, and heavy lid. On lifting this lid a second cover is removed. The center space contains a smaller zinc box around which crushed ice and salt are packed like an ice cream freezer. In this central box materials may be kept at a freezing temperature. At the end of the hall is a fine powerful electric centrifuge, which can be regulated, and registers the speed at which it is run. Such a centrifuge throws down red blood cells at once. Centrifuge glasses come in three sizes and are bought in large quantities. They are plugged with cotton and sterilized like test tubes. In this way, it is convenient to work with such a centrifuge. Near the centrifuge is placed the shaking machine. This is run by electricity, and fluids particularly extracts of organs and chemical mixtures are shaken in this machine.

Of some importance is the fact that there is a small carpenter shop in connection with the laboratory. A short bench, with outfit of tools, where the Diener makes special appliances whenever called on.

The animals belonging to the First Medical Clinic are kept in an outside building. Rabbits, guinea pigs, mice, and a goat are always in use. They are used not only for diagnostic or research purposes with patients in the wards, but also for out clinic patients.

To care for and assist those who do research, the new laboratory has two Dieners. They perform all the rough work, and are good, honest, faithful men. There is a great deal of work in any laboratory which the physician should not consume his time in doing.

His has put into practise his new and progressive ideas for the advancement of his medical clinic and for the study of medicine. The assistants must do research both clinical and of the laboratory kind. Therefore, he has surrounded himself with men who possess both qualifications. While clinical observations are just as important as test tube experiments, the combination of the two leads less often to

error.

Then again the establishment of a laboratory for research separate and distinct from the laboratory for minor clinical examinations is certainly progressive.

The first assistant in the first medical clinic is Dr. Paul Fleischman. He is a young man whom His has modeled out of good material. Fleischmann enjoys the distinction of being both a good clinician and a good laboratory man. He has obtained considerable prominence for his work upon serum diagnosis. He stands in the same class with Citron and Morgenroth as a serologist, and is the equal of de la Camp or Strauss in physical diagnosis. It is the aim

of Geheimrat His to develop assistants who can carry out scientific laboratory experiments and at the same time be able to go over patients with that other factor which we call clinical skill. Fleischmann possesses this. He may be seen any morning taking a history, and mak ing a physical examination and a few hours later you will find him injecting animals or carrying out some experiment in the laboratory. In appearance he looks very much like von Pirquet of Vienna. He practises medicine in Charlottenburg-that is like many of us, whenever he gets a patient. Personally, Fleischmann is what we call a gentleman. He is pleasant, enthusiastic, and a good fellow. He speaks English practically as well as Ludwig Pick, the pathologist, whom some of you know.

We have a first-class municipal laboratory in St. Louis in connection with the city hospital, just as they have a great Pathological Institute. at the Charite under the direction of Johannes Orth. But these institutions are wholly apart from what I am describing.

The laboratory of Geheimrat His is for the use of the medical clinic, and not for the hos pital in general.

It is to be emphasized that this laboratory is used for research by clinicians, that is men who examine and treat cases in the wards and who practise medicine.

While so much is being done by the St. Louis Medical Society towards the advancement of medicine in St. Louis and especially as so much is being said now about the reorganization of the medical clinic of the City Hospital, the following factors should be taken into consideration:

(1) Let there be a laboratory in connection with each medical service, well fitted, which is not a mere laboratory for the examination of urine, blood, or sputum, but a place where advanced research can be done.

(2) Have adequate money set aside to pay for supplies and necessary expenses for the running of the same.

(3) Arrange for janitor service which corresponds or is equivalent to the German Diener. That is men who can do a certain amount of technical work which cannot be done by the busy physician who wishes to do research.

(4) The laboratory should be so arranged that the physician can work at odd hours and as long as he wishes, because the busy physician can not do laboratory work at appointed hours, and have clinical work also.

(5) In this way you will have clinicians who are the equal of any in the world. They will be engaged not only in the diagnosis and treatment of patients, but also in clinical and laboratory investigation, and the young men whom they will develop will have the oppor

tunity and the stimulus to obtain both clinical and laboratory skill.

CARCINOMA OF THE BODY OF THE UTERUS.

BY C. C. VANDERBECK, M. D. PH. D., St. Louis. Mo

One object only is sought in reporting this case, and that is to stimulate the present tendeney to discover early cancers, or perhaps stated more clearly, to discover cancers early.

An article a few years ago by Dr. Crossen made me determine to be more rigid in my investigations of suspicious symptoms of cancer of the uterus, and thus give my patient the benefit of an early positive diagnosis.

Current medical literature since then has urged this careful scrutiny. The Richmond Journal of Practice, June, 1907, quotes Dr. G. E. Crile, who says: "Frequently there are welldefined predisposing causes and precancer states. The precancer stage is the preventable or curable stage. It is vastly better to prevent a cancer than to cure it. No specific therapeutic measures exist; the knife is still the most reliable means of treatment. In its beginning, cancer is always local and is curable by complete excision. The chances of cure diminish in inverse geometrical ratio to the lapse of time since its inception."

Such being the case, the duty of the profes sion is plain, to begin and keep up a cancer education, both to the laity and to the rank and file of the profession, that the first may recog nize suspicious signs and seek early medical council, and that the second may act promptly and intelligently in the matter. Both classes should accept the dictum, cancer is an absolutely local disease in the beginning and should be removed at the earliest possible moment after its presence is suspected.

Case: Mrs. McM., age 55, came to my office to consult me for some trouble with her menstrual periods. Menopause had not taken place apparently. She was regular each month, but for the past few years often her periods have become veritable hemorrhages. Some pain had developed in the pelvic region between months, a little leucorrhoea, but in no way offensive to the smell. There was no loss of weight. No cachexia. Negative family history. General health fairly good, appetite and digestion and bowels about normal.

Examination by speculum revealed an irritated cervix, os large and denuded, and with cystic mucous glands.

My first thought was to give a diagnosis of endocervicitis and treat her accordingly, but weighing the other conditions of pain, age and

excessive bleeding in my mind, I asked for consultation to clear up a possible incipient carcinoma.

Dr. Fred J. Taussig examined the case for me at the Skin and Cancer Hospital, and he had a microscopic study made of a clipping from the cervix. This gave negative results and yet for the same reasons that actuated me to further investigation he concluded to curette the uterus, examine the scrapings microscopically and at the same time to amputate the cervix.

Accordingly on December 19, 1908, this was done. The cervix was found to be noncancerous, but the scrapings from the uterus showed that the body was undoubtedly cancerous.

On December 22, 1908, a second operation was done by Dr. Taussig; a hysterectomy, per vaginam. It is needless to say anything of the operation itself, as the technic is well known. The extirpated uterus was found enlarged and undergoing a cancerous degeneration. Microscopically there was found beside a reduplication of glandular epithelium and marked hypertrophy of glandular tissue, a tendency for the glands to dip down deeply

into the muscular coat.

The sum of it all reverts to our primary position. We should act in keeping with the tendency of the day, find out by all possible means if a cancer exists, and then with promptness and decision, use the only sure means to save life under such circumstances; early extirpation. The object of this little article is attained in stimulating the profession to thorough and prompt work in all cases of suspic

ious cancer.

2007 Park avenue.

THE MARRIAGE OF THE BLIND FROM THE STANDPOINT OF A PHYSICIAN.*

BY CLARENCE LOEB, A. M., M. D.

He who undertakes to outline a course of conduct differing essentially from that followed by the majority of his fellows, attempts a thankless task. He will encounter remonstran ces, arguments, it may be difficulties and dangers. If, however, he brings to his aid a mass of facts, whose tendency is to support his position, he will at least command attention and even consideration. If the following paper seems overburdened by statistics, if it appears to abound in needless reiterations, let it be remembered that it is proposed to attack what many regard as one of man's inalienable rights, that of marrying whom he pleases. What shall it profit us to establish the fact of heredity

*Read Before the Medical Society of the St. Louis City Hospital Alumni and the Scotoie Aid Society of Missouri, Oct. 9, 1908.

in blindness and to proceed to propose measures for its prevention, if we are to be met at the end by the argument that society has no right to impose restrictions on the marriage of its members? Let us therefore first examine the right of the state to determine a man's qualification for marriage.

From the earliest records which we possess, it would seem that there were in the beginning no restrictions upon marriage save those im posed by the law of might. Polyandry or polygamy were universal. Jacob married two sisters, who were his maternal first cousins. Solomon is popularly credited with having had a thousand wives; a large number he certainly did have. It was no uncommon thing for the Ptolemy rulers of Egypt to marry their sisters. It is unnecessary to multiply instances, as these few will do for examples of unrestricted right to marry. Probably the first change was the introduction of the monogamous marriage which prevails now in all civilized lands, with rare exceptions.

The Catholic Church early took a stand against polygamy. It went further and forbade the marriage of people within the 4th degree of relationship. It is to-day the strongest opponent of the remarriage of divorced persons. Henry VIII of England left its fold, probably not so much because of a change of faith as because the Pope refused to allow him to divorce Catherine of Arragon and marry Anne Boleyn. In England, furthermore, there was enacted a law forbidding a man's marrying his deceased wife's sister, and this has only recently been repealed. In France, a civil marriage is necessary, whether an ecclesiastical one is performed or not. In nearly all the states of the Union, a marriage license is required before a minister is allowed to perform the ceremony. In all, people below a certain age are forbidden to marry without their parents' consent, while insanity at the time of the mar riage is grounds for nullifying it. Laws are in force in a large number of states preventing the intermarriage of the black and white races, and even where such laws have not been enacted, the force of public opinion usually acts as a bar. Finally, in a large and increasing number of states, marriage between relatives as close as first cousins is forbidden. So I take it, there can be no question that the state has the right to regulate marriage and to say what qualifications are necessary. If therefore it shall appear from what is to follow that the marriage of the blind is detrimental to the best interest of Society, it cannot be denied that it is the right, if not the duty, of the state to prevent such marriages.

Before we proceed any further, it will be necessary to define the terms to be employed.

There is no more fruitful source of argument than a misunderstanding of terms. For instance the word blindness may mean almost any degree of loss of sight up to complete inability to perceive light directed towards the open eye. In this paper, wherever the word "blindness" is used, it will mean such a diminution of sight as to seriously impair the patient's chance to earn a livelihood. It does not include those cases where by the use of proper glasses or proper medicinal treatment the vision is restored to practically normal, but does comprise those cases where an operation is necessary before the patient has a good working vision. I feel that I am justified in excluding the former, because the use of glasses is as much a recognized necessity to-day as the use of street-cars, while diseases of the eyes which are amenable to medicinal treatment are only temporary in their bad effect. Where an operation is necessary, however, it is usually attended with some degree of danger, either from the use of the anesthetic or to the eye itself, which make the disease a more formidable condition.

The eye may be compared to a camera, whose lens corresponds to the cornea, or clear part of the eye, and the lens of the eye. The box is comparable to the chamber of the eye en closed by the white of the eye, which is called the vitreal chamber. The sensative plate may be compared to the retina, which contains the rods and cones, by means of which we see. The optic nerve and the centers for sight in the brain are comparable to the developing fluid. The photographer secures a better definition of the picture on the plate by moving the latter backwards or forwards. The same effect. is obtained in the eye by means of the ciliary muscle which increases or diminishes the strength of the lens. Finally, the camera has a shutter by means of which the amount of light entering it is controlled. This function is taken in the eye by the iris, or colored part of the eye, whose movements any of you may test. Now, just as in the camera, defects in any of these parts will result in blurring or total loss of the negative, so also in the eye, diseases or malformations of the cornea, lens, iris, vitreous, retina, or nerve will result in greater or less loss of sight, that is to say in more or less blindness. I will discuss later on what diseases of these are hereditary in character and will now explain what is meant by the term heredity.

If we look upon the world around us, we will find it full of innumerable forms of life, each differing to a greater or less degree from, yet each connected by relationship more or less remote with all others. By virtue of these differences, and resemblances, biologists have

been able to classify these forms into kingdoms, sub-kingdoms, families, orders, suborders, genera and finally species. When the members of one species differ in any way from each other, they are classed as individual varieties. There are two theories to account for the existence of so many different species of animals and plants. The older, ecclesiastical doctrine claimed that God created each form as it then existed. The modern theory, which dates from Darwin, claims that the species that now inhabit the earth are descended from earlier, simpler forms. This evolution is brought about by two distinct factors: First, there is the tendency of each species to reproduce its characteristics in its offspring-in other words the process which we may call heredi-. ty in its wildest sense. It means nothing more than that the progeny of a dog is a dog. of a maple is a maple, etc. The second factor is the tendency of each form of life to differ, be it ever so slightly from its progenitor. These so-called variations, under favorable conditions, tend to perpetuate themselves and in turn are replaced by new ones, until the descendents of one parent stock may differ so widely from one another that the fanily tree may be difficult to trace. Charles Darwin traced the different forms of pigeons existing in England at his time to the parent stock of the common rock-pigeon, and thus gave a new and firm foundation to modern Biology. Who gazing at the full-blown pride of the American Beauty Rose would recognize its descent from the common wild-rose? Yet changes as marvelous as these are being constantly wrought in the workshops of men like Burbank, who take advantage of the two factors of heredity and accidental variation to produce new forms of plant life. The same thing has been done in the animal kingdom, as is testified to by the numerous kinds of domestic animals. This development of new forms from old proceeds rapidly at the present time, because it is under the fostering care of an intelligent being, who discards what is disadvantageous and preserves only what he considers beneficial. In the hit or miss method of Nature, a varia tion if it is to become established at all and develop into a new species requires years and even centuries. The beginning and the end of the process are never seen by the same generation, while the heredity of forms occurs daily and is patent to all. Therefore, before the leaven of Darwinism had worked among the masses, it was believed that every form of life was originally created as it then existed and would continue to reproduce itself exactly as it was.

We must remember, however, that not every new variation is a favorable one. There are

as many if not more unfavorable ones, which under the same law of heredity would tend to perpetuate themselves. But in a state of Nature, the variations which were favorable to the life of the individual and helped it in its struggle for existence were reproduced in the offspring. Those which were unfavorable were soon lost in the death of its unfortunate possessor. So has come about the wonderful adaptation of life to its surroundings of which we find evidence on all sides. In the state of Society, however, where we are dealing with the love of parent for offspring, a disease or malformation serves usually to awaken even a deeper love than that for the normal child, and all the fostering care of civilization is evoked to aid in bringing him to man's estate. Arrived there, if he succeeds in marrying, he is in the position of being able to reproduce his kind. Therefore, in the state of Society, or Civilization if you prefer, we are brought face to face with the problem of the perpetuation of inferior forms of life. The ancient Greek who exposed his malformed child to the destroying elements was acting in conformation with the law of Nature which proclaims that the fittest shall survive. To-day, if the parents are unable to care for the unfortunate child, he is placed in some eleemosynary institution where he receives the care of persons specially trained to provide for his needs. I am not advocating a return to the Spartan measures of our ancestors. No one subscribes more fully to the belief that a being born into this world is entitled to its care if he is unable to compel it, but having gone so far, I fail to see that it is the duty or even the right of Society to permit him to perpetuate his special brand of misfortune.

Viewed in the light of evolution, therefore, heredity is the tendency towards the reproduction in the offspring of the characteristics of the parents. Used in its pathologic sense, it means the reappearance in the descendant of some abnormal condition in the parent. It is even broader than that. It means, first that the actual disease or malformation found in the parent may reappear in the child; or second, some correlated condition of the original disease or malformation may be present in the child; or third, only the tendency towards the disease or its correlation may be transmitted, so that several intervening generations may be apparently free from the pathologic condition. In this lapse of time, the original source of the hereditary taint may be lost sight of, and the disease thus seems to start as a primary condition. As a consequence of this third form, several children of apparently normal parents may be affected, and thus show the hereditary character of the disease. Accordingly, we have

no

three forms of heredity: First, the direct, where the same disease or one of its correlates appears in the child at about the same age as it did in the parent, or even earlier. In the latter case it is said to anticipate. The second variety of heredity is called the indirect and occurs when the offspring suffers fron some disease or malformation, of which trace appears in either of the parents, but which is found in one or more uncle, aunt, or grandparent, no matter how far removed. The condition is then said to be latent in the parent, and only the tendency is inherited. The third form of heredity is called collateral inheritance, and occurs when two or more members of the same generation, brothers and sisters or cousins, are affected, without any record of a similar condition in any member of a previous generation. Here, too, the tendency alone and not the actual pathologic process is inherited. If careful search through the family history reveals the same condition in some progenitor, the form changes from collateral to direct or indirect, usually the latter.

Another point that must be considered is the difference between heredity and coincidence. If an uncle should lose an eye by an an injury and a nephew should subsequently be born with the same eye blind, such a fact would be a coincidence. If the same should take place in the case of parent and child, it would also be considered a coincidence unless a sufficient number of such cases could be found to show that it was the rule rather than the exception.

Finally, it is necessary to distinctly understand one point. The absence of the same disease in children of blind parents is more or less of an argument against heredity. It is true that the disease may be only latent and may reappear in subsequent generations, but it must be taken into consideration in estimating the proportion of children of blind parents who will become blind. Furthermore, it frequently happens that while some of the children of blind parents are blind, others are not. Therefore in collecting cases of inherited blindness, I have always tried to get the number of normal children in each family. But the statement has been frequently made that such and such normal parents had a blind child, from which fact it is argued that blindness cannot be hereditary, otherwise the parents ought to have been blind also. This is absolutely illogical. The disease must start somewhere and from some cause other than heredity. It may be one of the unfavorable variations of which I spoke when discussing evolution, or it may be the result of some constitutional disease present in the parent. Malformations have frequently been ascribed to