THE PRACTITIONERS' MONTH

!>IUKAgi

DETROIT

MEDICAL
JOURNAL

VOL.. II. JANUARY, 1903. no. -io

editor:
FRANK BURR TIBBALS, M. D.

COLLABORATORS :

A. W. IVES, M. D. JOSEPH SILL, M. D. H. Jj^JiARI^, M. D.

V ^

SURGICAL CLINIC AT HARPER HOSPITAL, f |^n t ?) ^^ ^ |

•H. 0. Walker, M. D.; - - l ^ '^ '^ , 674 '^' '

UREMIA : A RESUME OF THEORIES AND. RE^fiiftCH.

Homer E. Safford, M. D.; - - - - 681

RECURRING TONSILLITIS,

Jno. A. Donovan, M. D.; - - - - 691

MEDICAL CONSIDERATIONS ; _ _ . 693

EDITORIAL; - - - - - 696

EDITORIAL NOTES; ----- 698

NEW INSTRUMENTS AND DEVICES; - - 700

BOOK REVIEWS; ._ - - - 702

ADVERTISING INDEX; _ - _ - xi

DETROrr MEDICAL JOURNAL 0> PUBLISHERS.
270 WOODWARD AVE. DETROIT, MICH.

CNTEHCO AT THE POST OrPICC AT OCTIieiT, MICH., AS •KeONO CLASS MATTKR MAY STH. tSOI.

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?r* " — ~ — ^

TRUE
ANIMAL IRON

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Physicians everywhere are looking for a Blood
reconstructant that contains every element of nutrition
of the animal, mineral and vegetable kingdoms, viz.:
Animal Iron; a reconstructant that will supply
every deficiency in the blood of anaemic patients in
adequate quantity and quality : one that will nourish —
stimulate — assimilate — without tax on the digestive or-
gans. These requirements are all found in perfection in

BOVININE

I

It Contains 10% Animal Iron* t

20 % Coagulable Albumen, and all the constituents
of healthy Blood.

It is thoroughly sterile, requires little or no diges-
tion, and produces blood corpuscles that Mattire.
Corpuscles of fullness and integrity. Herein lies its
great superiority over any and all the preparations of
inorganic iron. Your microscope will prove the truth
of these facts. Our scientific treatise on Haematherapy
for the asking. It contains reports of hundreds of cases.

♦

$♦*

THE BOVININE COMPANY

75 West Houston St.. New Yorh

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J

DETROIT MEDICAL JOURNAL.

THE,

rny-5cheere:r co.

Mantxfaffltirers of and Dealers i*k

High-Grade
Surgical

Instruments

Hospital
and Office

Supplies.

I

225 to 233 Fourth Avenue, NEW YORK CITY.

I

The largest establishment
States. Carrying the most

SURGICAL INSTRUMENTS,
MODERN ASEPTIC HOSPITAL

SUPPLIES,
ASEPTIC OPERATING, WARD

and OFFICE FURNITURE,
STERILIZERS and DISINFEC-

TORS,
NURSES' REQUISITES,
SICK-ROOM UTENSILS,
RUBBER SURGICAL GOODS,
SANITARY APPLIANCES,
DEFORMITY APPARATUS,
TRUSSES,

ABDOMINAL SUPPORTERS,
SHOULDER BRACES,

of the kind in the United
extensive and complete line of

ELASTIC HOSIERY,
CRUTCHES, SPLINTS,
[NVALID CHAIRS,
ASEPTIC SURGICAL DRESSINGS,
BANDAGES and PLASTERS,
ELECTRIC BATTERIES and

APPLIANCES,

MASSAGE INSTRUMENTS,
ANATOMICAL MODELS,
OSTEOLOGICAL PREPARA-
TIONS,

LABORATORY SUPPLIES,
NATURALISTS' INSTRUMENTS,
MICROSCOPES and ACCES-
SORIES, ETC., ETC.

Correspondence Invited.
Inspecftion of PREMISES and STOCK SOI.ICITED.

Catalogues Mailed FR££ on Application.

DETROIT MEDICAL JOURNAL.

Morrison's

Surgical

Pad..

THe Best

Most Convenient

and

Most Practical

<^ The Davidson Rubber Co.

19 Milk street,
BOSTON. MASS.

DETROIT MEDICAL JOURNAL.

Ill

.».».». ».♦.».».♦.».♦.♦.♦. ♦.».♦■

For rough usage,
dishwashing, etc.,

Non=Pa=Ren
Gloves . .

have no equal.

For sale by all jobbers.

Booklet free. .

Ih^ Faultless
Rubber Glove

is the best glove your money can buy.

CAN BE STERILIZED REPEATEDLY.

Made in four weights and in sizes and i half sizes
from 6 to n inclusive.

THE FAILTLESS RUBBER CO.

AKRON, OHIO, U. S. A.

,♦.».».».♦.♦.♦.♦.♦.♦.♦.♦.♦♦.♦.».♦.♦.♦.♦.♦■».».».♦.♦.♦.♦.♦.♦.»,

IV

DETROIT MEDICAL JOURNAL.

THE COLUMBUS

ASEPTIC OPERATING TABLE

AND CHAIR COMBINED

1

I *<t%r*u

TWrade without complicated mechanism, easily adjusted to the

largest number of positions possible on any one operating

apparatus. Finished in white enamel unless

otherwise directed. _ _ _

Price $25.00

"^^I^Jt^

MADE ONLY BY

i The Columbus Pharmacal Co.

63-67 E. Long St.

ST. LOUIS, MO.

MANUFACTURERS OF ALL KINDS OF HOSPITAL AND OFFICE
FURNITURE. CATALOGUES SENT ON APPUCATION.

DETROIT MEDICAL JOURNAL.

WRITE FOR
CATALOGUE

It explains about these, and about
JOO more different sizes and styles of
Medicine Cases, Obstetric, Instru"
ment and Emergency Bags, also
Vial Cases of every description.

Western Ledwther
Mfg'. Company

48 Wabash Avenue
= CHICAGO

VI

DETROIT MEDICAL JOURNAL.

THIS IS PRACTICAL!

ntosti PortafilG Dry Ceil Galvanic & Faradic Batlery

Physicians have long felt
the need of a Portable Dry
Cell Galvanic and Faradic
Battery giving a current
sufficient for all treatments
and which can be easily car-
ried to the patient's bedside.
When cells become ex-
hausted, the doctor can re-
place them with new ones.
We use the Columbia Dry
Cell, which can be had of
any Drugffist or Electrical
Supply House.

The Galvanic Batteuy
consists of 43 Cells (13^ volts
each), perfectly controlled
uy Graphite liheostat and
measured by Mcintosh Mil-
liamperemeter graduated
from to 150 Milliamperes.
The Faradic Battery
has Primary Coil wound
with 300 feet Ko. 20 wire,
while the Secondary Is
wound with 1,300 feet of
No. 30 wire. The adjust-
ment of the Singing Kheo-
tome gives wide range of
interruptions.

SEND FOR ILLUSTRATED CATALOGUE AND PRICE LIST.

BATTERIES, ELECTRODES. STATIC MACHINES 4, X-RAY COILS.

McINTOSH BATTERY AND OPTICAL CO.

39 W. Randolph St. - CHICAGO, ILL.

♦4jf)f3f)f>f)fjf)f3fjf)f3fjf)f)f4*Jf5fjf4*3f*^-5f**>f3f**3f*5f'f**)f*********4***Jf>f43f**^

DOUBLE TRACK ALONG
OHIO'S GREATEST RAILWAY

THE nOCKINQ VALLEY

HOURS

TO

If.

COLlMBlS J

•¥■

UNION STATIONS $

IN *

TOLEDO, t
COLUMBUS t

AND if-

ATHENS. J

< J

*

L. W. UNDMAN, J

Gen. Trav. AgL, ^
AC-
DETROIT, MICH, t

?t^t*-K-K'K**-K*-K****************************+******************-K***-K***

DETROIT MEDICAL JOURNAL.

VII

♦»♦»♦«♦*♦»♦«♦«♦■♦»♦»♦»♦«♦«♦«♦»♦«♦»♦«♦»♦« 4 » «♦»♦»♦«♦»♦»♦»♦»♦»♦«».♦.

THE WISE DOCTOR SPECIFIES

£fi

TWIN-BULB"

WHEN ORDERING A FEVER THERMOMETER.

IT IS THE STANDARD OF ACCURACY.

REGISTERS QUICKER, SHAKES DOWN EASIER, AND COSTS
NO MORE THAN OTHER MAKES.

FOR SALE BY ALL

DEALERS IN

PHYSICIANS' SUPPLIES

PRICES :
2 Minute in H. R or Aluminum Case,

Eacli, $1.00
1.25
1.50

BECTON, DICKINSON & CO., N. Y., Makers.
♦■♦«♦'♦»♦»♦'♦■»»»♦»♦»♦»♦*♦«♦«♦*♦«♦»♦»♦»♦«♦«♦»♦«♦«♦»♦«»»»»♦»♦.♦.♦.

^■^^■^^■^■^■^^■^^■^■^■^■^^■^■'

EVERY PROGRESSIVE PHYSICIAN

realizes that he should have an efficient Sterilizer as part
of his office equipment.

EVERY HOSPITAL KNOWS
that a Sterilizer is essential.

ROCHESTER COMBINATION STERILIZERS
meet the requirements of both hospitals and physicians
better than any apppratus made.

HOT AIR = STEAM - BOILING WATER
all complete in one apparatus.

High or low stands with burners for gas, alcohol, kero-
sene or electricity furnished, or Sterilizer can be heated
on an ordinary stove without stand.

Send for our latest booklet, or ask your instrument
dealers about them.

WILMOT CASTLE & CO.,

8 Elm Street,

ROCHESTER, N. Y.

I The ''Baker''

ADJUSTABLE

Bedside and Reading Table

A Perfect Device for Comfort

Indispensable in the Sick Room.
Our Interesting Booklet Mailed Free.

J. R. BAKER & SONS CO.,

26 Wayne St., KENDALLVILLE, IND.

VIII

DETROIT MEDICAL JOURNAL.

DOCTOR PHELPS

An authority and leader in Orthopedic
Surg^ery, speaking of the

Ambulatory
Pneumatic Splint

In the treatment of Leg, Thigh and Hip
Fractures said:

"It is the culmination of the evolution
of the treatment that we have been going
through."

This appliance is by far the best, as
well as the cheapest, dressing in the mark-
et. The same appliance is adjustable to
any adult, and is used many times on
different cases.

Write for clinical reports, prices and
discounts.

164-166 East Randolph St.,
CHICAGO.

CARRIED IN STOCK BY

F. HARTZ CO.,

Woodward Ave., DETROIT, MICH.

The Ladies' Perfect Syringe

r

\

improved by the addition of

an Adjustable Spray Tip.
THE ONLY PERFECT VAGI-
NAL AND RECTAL SVRINOE
IN THE WORLD.

THE BEST SYRINGE
Invented for making Vag-
inal Injections without
leaking and soiling the
clothing or necessitating
the use of a vessel, and
which also can be used
for Rectal Injections or
Irrigations and Spray ef-
fects.

The Syringe is operated
by using the ring handle,
to push or double the
thin flexible half of the
bulb into the thick, firm
part, and to draw it out
again. This pumping mo-
tion first injects all the
fluid into the vagina, and
then draws it back into
the bulb, with all the uis-
charges.Our new Adjusta-
ble Spray Tip greatly Im-
proves the syringe, af-
fording the opportunity to
produce a flne spray or a
veritable deluge of water
by simply turning the
screw head on end of
spray tip.

It will pay you to handle this
article.

Ask your Jobber for Prices and Further
Particulars, or Write us direct.

THE B. F. GOODRICH COMPANY,

Akron Rubber Works, AKRON, OHIO.

New York, 66-68 Reade St.
Chicago, 141 Lake St.

Boston, 157 Summer St.
San Francisco, 39a Mission St.

Truax's
MuItipleNebulizer

Most Satisfactory Nebulizer Ever Manufactured

A PERFECT INSTRUMENT
CONSTRUCTED ON NEW PRINCIPLES
SECURES THE BEST RESULTS

= FEATURES ==

1. Separate tubes for compressed air and vapor,
both of which may be used at the same time and
two or more patients treated simultaneously.

2. Vapor from two or more of the bottles may be
mixed and form a single stream, thus securing any
desired combination.

SEND FOR BOOKLET SHOWING ALL THE STYUS MANUFACTURED

Truax, Greene & Co.,

42-44-46 Wabash Ave.

CHICAGO

DETROIT MEDICAL, JOURNAL.

IX

I'
O

II

II

i>

II

1 1

II

o

II

Surgical Phlebotomy ;;

II

Shocks the patient. Depletes the lung by reduction of vital tissue. i

Every red blood-corpuscle is an oxygen carrier. Pneumonia patients *^

bear loss of blood badly. Bleeding necessitates administration of ^^
free oxygen.

Physiological Phlebotomy Is Rational
Therapeutics

Bleeds But Saves The Blood

Antiphlogistine is the only known and approved medium for Physi-
ological Phlebotomy. Relieves the congested lung through the
physical process of osmosis. Aids resolution by abstraction of
Liquor Sanguinis. Maintains circulation by saving vital tissue.

ANTIPHLOGISTINE

Is immediate, effective and permanent in its action. Pleuritic ad-
hesions do not occur and Cardiac complications are prevented in
those cases where

ANTIPHLOGISTINE

is applied in the initial stage of Pneumonia, Pleurisy, or Pulmonary
Congestion.

Denver Chemical Mfg. Co.,

London, Eng.

New York,

4. »■».». ♦.♦.♦.♦.♦.».♦.».♦.♦».».»■».».♦.».♦.♦.♦.♦.♦.♦. 4

DETROIT MEDICAL JOURNAL.

IT DOES THE
BUSINESS.

IT NEVER
6RIPE5.

ABBOTT'S I

EFFERVESCENT'

Saline Laxative

(SckKitxSiItjj

(ChviniiAlly purt mat'nfiiium jutpliuie"
^ incfTcrvncenicombmalioiij

a»_„ AN 'DEAL.

RERSJGERANT, ANTI-FERMENT

ANT-ACID

UXATIVE OR cathartic!

According to pose 4nd Concliiion.'

THE ABBOTT ALKALOIDALCO.

WORI^S LIK.E A. CHA^FH^.

^~^ m -m WTPM-JTW M. 'nthe rheumatic diathesis.

^^% /\^ I ^ g £ IMMi^^ ^^^^ THING (A LITTLE LESS LAXATIVe)

WITH SOLUBLE. LITHIUM ADDED

^PRINCE m ELIMINANTS

To clean out with Abbott's Saline Laxative, to clean up with the W-A
Intestinal Antiseptic and to keep clean by proper living- and repetition of the
same as needed (with perhaps a little strychnine arsenate to take up the slack)
is the key note to the treatment of most of the every-day ills of modern
civilization, and there is no age or condition from the cradle to the grave in
which this treatment may not be used with success when indicated.

DOCTOR TRY IT AND SEE.

On sale at principal pharmacies. All leading- jobbers are supplied. Send
for samples and literature if you like. Yours for the asking. Don't wait,
make a few tests on prescription. We vouch for results. If your drug-gist
won't supply you we will. Send for price list of our full alkaloidal line.
Your money is good — gets lowest prices.

9S^ lOO LeBLdlnit Jobbers a.r« Sxjpplled "^0

THE ABBOTT ALKALOIDAL CO.

Ravenswood Station
CHICAGO

Branches:

93-95 Bro»d St.. New York

13 Phelarv BIdg.. San Francisco

DETROIT MEDICAL JOURNAL.

XI

BISSELL WILSON, D. P. A.,

1 1 1 Adams St.. CHICAGO, ILLS.

*<r%r«/

H. D. ARMSTRONG, Travellinq Passenger
Agent, 32 Campus Martius, DETROIT, MICH.

INDEX TO ADVERTISERS:

Abbott Alkaloidal Co X

Albasulphidi XXVI

Ambulatory Pneumatic Splint Mfg. Co.. VIII

Baker, J. R. & Sons Co VII

Bauscb & Lomb XXV

Becton, Difckinson & Co VII

Biogen Co., The XV

Bovinine Co Inside Front Cover

Cannabin Tablets XIII

Carliczek, Ottomar Co XXIV

Carpenter Chemical Co XVIII

Castle, Wilmot & Co VII

Chloride of Silver Dry Cell Bat'ry Co. XXVII

Columbus Pharmacal Co IV

Crittenton, The Charles N. Co XVI

Davidson Rubber Co II

Denver Chemical Mfg. Co IX

Denver & Rio Grande XXV

Dios Chemical Co XXI

Electro-Therapeutic Mfg. Co XX

Engeln, H. P. & Co XIV

Faultless Rubber Co Ill

Franco-American Chemical Works... XXIV

Fries Bros XXXI

Glogau Co., The XVIII

Goodrich, The B. F. Co VIII, XXXI

Grosvenor, The J. M. Co XXVIII

Hartz, The J. F. Co XII, XXV, XXX

Hastings & Mcintosh Truss Co XXIX

Hocking Valley VI

Hospital Sheeting Co XVIII

Howard Electric Novelty Co XIV

Hussey, E. J. & Co XXXI

Iron Mountain Route XI

Johnson & Johnson Inside Back Cover

Kny-Scheerer Co I

Lambert Pharmacal Co Back Cover

Lee, The J. Blwood Co XXII, XXXII

Mcintosh Battery & Optical Co VI

Nelson, Baker & Co XXIII

Polk, R. L. & Co XXXI

Practice for Sale XIV

Professional Cards XVII

Tagliabue, Charles J XXIX

Truax, Greene & Co VIII

Upjohn Pill & Granule Co XVI

Victor Electric Co XIX

Waite & Bartlett Mfg. Co XXI

Warren, Charles W. & Co XXVII

Weeks Drug & Chemical Co XXII

Western Leather Mfg. Co V

Woman's Hosp'l of the State of Mo.. .XXXII

XII

DETROIT MEDICAL JOURNAL.

THIS CABINET

WILL COST YOU $30

White Enameled Interior.

Bevel Glass Door.

Three Plate-Glass Shelves, Front Edges Polished.

Five Drawers, White Enameled Interior.

Made of Handsomely Finished Oak.

Slide Rest for Instruments,

Pail Compartment.

Steel Enamel Pail, $1.50 Extra.

74 inches high, 27 inches wide.

Body, 36 inches high. Shelves, 12 inches deep.

Stand, 14 inches deep.

THE J. F. HARTZ CO.

268 "Woodward Avenue,
DETROIT, MICH.

2 Richmond Street East,
TORONTO, ONT.

Oldest and Best Manufacturers of Medicine Cases and Bags in the Country

Established 1856. Below are pictures of two of our hundred styles.
Write to your trade for the Comstock-Hoff complete catalogue.

New Solid Sole Leather Emergency Case new cabin or emergency bag

Case 42 D. Open.

Each

We bring to the profession a very attractive bag
of the latest and most desirable pattern, combining
all the merits of the Cabin Bag in a form which Is
perhaps, more pleasing in appearance, and at a
somewhat lower price. The quality of leather and
workmanship is quite the equal of any of our
other goods. Washable lining. Loops are upon both
sides of the lids. PYames of brass nickeled or brass
polished. Height of bag, 8\<i in.; width, 5\(t in.

PRICES WITHOUT BOTTLES:

15 inches $4.00 I 17 inches W.60

16 Inches $4.25 j 18 Inches $4.76

Fitted with 6 glass-stopped bottles on removable

card, 75 cents extra.
Fitted with 6 glass-stopped metal-capped bottles
on removable card, $1.25 extra.

L^SirX^^g^l.'^adet^r'"" The Comstock-Hoff Mfg. Co., New York.

No.

42 D. A case constructed of solid leather pressed
Into Shane. Contains no wood nor paper
nor cardboard in the construction of its
frame, which is of solid leather only.
Holds 26 4-dr. and 10 6-dr. corked vials;
also 4 1-ounce Glass Stop metal-capped
bottles and space for sundries. Price f7.60

DETROIT MEDICAL JOURNAL.

XIII

CANNABIN
TABLETS

$1.50

PER

1,000

(FORMULA)

Cannabin, - -
Zinc Phosphide,
Strych. Phos. -
Avenine, - -

1-10

- I-IO

1-40

1-200

grain
grain
grain
grain

75c.

PER

500

$6.00 PER 5,000
ANODYNE, ANTISPASMODIC, APHRO-
DISIAC, HYPNOTIC, NERVINE, RECON-
STRUCTIVE, ROBORANT, SEDATIVE

SAMPLE testimonial:

OFFICE OF

C. L.GISH, M. D.,

24 E. Genesee St..

Wellsville, New York. », , „

November 15, 1902.
The J. F. Hartz Co.,

Detroit, Mich,
Dear Sirs :— I would like another 5,000 of your CANNABIN TABLETS.
1 find them very satisfactory, 1 hope you will keep them up to the standard of
excellency. 1 enclose $6.00, Please send as promptly as possible.

Very truly,

(Signed) C. L. GISH.

The J. F. HARTZ CO., Mfrs.

DETROIT, MICH.

TORONTO, ONT.

XIV

DETROIT MEDICAL JOURNAL.

For Sale.

NEW PHYSICIANS' AND DENTISTS* ELECTRIC

ILLUMINATING DIAGNOSTIC LAMP

Established medical practice, paying over
$5,000 yearly. All cash oflace business. Located
in city of 16,000, in Central Michigan, the most
prosperous manufacturing town in the state.
An excellent opening for an M. D. The Doctor
is retiring, to take up work in a Sanitarium.
Will stay long enough with successor to thor-
oughly introduce him. Office rent, suite of four
rooms, only $16.00, Price, for stock, fixtures,
furniture and good will $1,100 cash. If you
mean business, write at once for full partic-
ulars.

WM. A. MONFORTON,

819 CKaxnber of Commerce,

Detroit* MicH.

PATCNT PCNOINS

Compact and complete in every particular. Fitted with the
famous " Reliable " dry batteries. Price, complete with bat-
tery, $5.00. Battery renewals. 50c. Lamp renewals, 75c.

HOWARD ELECTRIC NOVELTY CO.,

6 Howard St.

INCORPORATED

NEW YORK.

H. P. ENGELN & CO., Mfrs

May
ipparis

Our spark
Induction Coils
can be
connected
with any
v Incandescent
Lamp Sockets
They are
guaranteed
against any
break-down.

90 PROSPECT STREir.

CLEVELAND,* ^

DETROIT MEDICAL JOURNAL.

2

H,D

A new chemical
compound dis-
covered by Dr.

Friederick Elias
B e:rlin

GERMANY

BIOQEN, or MAQNESIUfl DIOXIDE (MgO,), is a true definite chemical
compound which liberates a high percentage of active nascent oxygen in the
economy.

According to Fresenius, of Wiesbaden, and Prof. Henry Leflman (Vice-
President of the British Society for Public Analysts) BIOGEN contains 33i^ per
cent. Magnesium Dioxide (MgO,) ; therefore this new substance exceeds by its high
content of oxygen (28 per cent.) all other similar agents as well as its stability and
freedom from irritant, astringent and corrosive action.

BIOOEN (MgO,) may be adrninistered in massive doses without disagreeable
or untoward effects. Upon disintegration it gives up its oxygen freely in the
stomach and intestines, which in turn is taken up greedily by the capillaries.

BIOQEN has all the good properties of iron without its constipating effect, all
the advantages of arsenic without its toxicity.

GENERAL INDICATIONS

BIOQEN (MgO,) is indicated when there is a deficiency of the blood in its bulk
or its normal constituents. For this reason it is invaluable in all forms of anemia,
tuberculosis, uric acid diathesis, leukemia, Hodgkin's disease and Addison's
disease.

VAN NOORDEN, of Frankfort, Germany, has found it extremely useful in
Diabetes Mellitus, as it reduces the glucose and exercises a marked influence in
the rapid oxidation and diminution of urea in the blood.

It controls dyspnea inherent to certain morbid conditions of the organism.
In pneumonia it has given the most satisfactory results.

Furthermore, it is a most effective prophylactic in septic conditions, acting
directly on the blood throughout the entire organism. Its field of therapeutic
activity in that direction alone is limitless.

In all disturbances of the respiratory and circulatory systems, such as Pneu-
monia, Asthma, Pulmonary Tuberculosis and Membranous Laryngitis, positive
benefit has been derived from the use of this product. In oxidizing and promoting
elimination of waste tissue it is without a peer in Materia Medica.

BIOQEN, MAQNESIUM DIOXIDE (MgOj), has exhibited its potency in such
a wide variety of diseases that a liberal supply of samples and clinical reports of
its value will be furnished to physicians on application to

TKe Biogen CompaLi\y

90 WILLIAM STREET NEW YORK

XVI DETROIT MEDICAL JOURNAL.

THE NEW DIGESTIVE

CARIPEPTIC LIQUID

The Vegetable Digestive

Digests all kinds of food.
Active in either acid, alkaline or neutral media.
Is indicated in all digestive derangements where a powerful
digestive and antiseptic stomachic is needed.

We Guarantee Satisfaction.

Price $1.00 per pint. $4.50 per 5 pints.
Literature and liberal samples will be sent to any physician
upon request. Prepared only by

The Upjohn Pill and Granule Co.,

Manufacturing Pharmacists. ; ; KALAMAZOO, MICH., U. S. A.

AFTER TYPHOID

/"^olden's Liquid Beef Tonic supplies nutriment in a
form eagerly accepted by the depressed vital organs.
Blood is enriched, tissue formed, nerves strengthened, the
whole system invigorated. It helps the patient out of
debility into healthful activity. Be sure to specify
definitely to insure the patient's getting the genuine
Colden's Liquid Beef Tonic. Sold by druggists generally.

Samples free to physicians.

THE CHARLES N. CRITTENTON CO.

SOLE AGENTS FOR THB UNITED STATES

115-117 FULTON STREET, NEW YORK

SURGICAL CLINIC

DECEMBER e. nooa AT H A R P EI R HOSPITAL

Bv H. O. WAL-KER, M. D.,

Detroit, Mich.

ABDOMINAL H VSTEIR EICXOM V

Gentlemen :

I have today, a series of interesting
cases that represent some common forms
of abdominal surgery, the first of which
is a uterine fibroma, not very large in
size, but of sufficient annoyance to de-
mand, in my opinion, surgical interfer-
ence.

This woman, Mrs. N., aged 46 years, of
very quiet habits, has never borne chil-
dren, nor has she had a miscarriage. I
have said fibroma, yet it is possible a
malignancy may exist. A very distin-
guished abdominal surgeon of another city
pronounced it either one or both, that is,
he was in doubt as to the character of the
growth. Non-fecundating women, how-
ever, are more prone to fibroid tumors of
the uterus, while malignancy is more
common in women who have given birth
to a number of children. This patient
has had several menorrhagias, first slight
in May of 1902, worse in June, with pain
in back. In July it was very severe, last-
ing three days, from which she fainted.
During the months of August and Sep-
tember the hemorrhages were about the
same, while during October she flowed
the entire month, and a part of Novem-
ber. The last severe hemorrhage was on
November 17. Her general appearance
is that of having lost flesh, anemic, with
a yellowish tinge. She has a constipated
habit of ten years' duration, with bladder
and general nervous irritabilty. Inspec-
tion shows lower abdominal prominence,
and by bimanual manipulation there is no
difficulty in mapping out a movable
spherical tumor, comfortably filling the
pelvic cavity. Having made our diag-
nosis, the question is, what shall we do
and how shall we do it?

Detroit, Mich., January 15, 1903.

It is my judgment that we do a hyste-
rectomy and through the abdomen. Al-
though the tumor is not large, it would
be a difficult procedure to remove it
through the vagina, and the haemostasis
would have to be done by forceps and not
by ligature, and I do not think a vaginal
hysterectomy, when forceps have to be
clamped on the uterine and ovarian
arteries, should be done. In the first place
the forceps are instruments of torture,
and in the second place the sloughing
stumps are so liable to sepsis, when if
ligatured and the pelvic floor closed,
these conditions do not exist. A small
vagina, as in this case, precludes a satis-
factory vaginal hysterctomy. We will
therefore proceed to do an abdominal
hysterectomy. Our preliminary work of
emptying the bowels with two ounces of
castor oil, hot bath, abdominal shave and
vaginal antiseptic douche, together with
our present ten minutes' wash with hot
water and soap, alcohol and final bichlor-
ide solution immersion, has been rigidly
performed, we are ready to make the
median abdominal incision through the
integument, fat, fasciae and linea alba,
when the peritoneum is caught by two
forceps, between which it is carefully
cut so as not to injure either the intestine
or bladder. Although the bladder has
been emptied, yet I have seen it extend
so high up, as to have been mistaken for
a thick peritoneum and unwittingly cut,
as well as the intestine, when done care-
lessly. The incision extends up a little
more than half way up to the umbilicus
from the symphysis. In passing my hand
into the abdomen to ascertain if adhes-
ions exist, I find none, but do feel a fairly
good sized hydrosalpinx on the right side.

Vol. 2, No. 10.

674

SURGICAL CLINIC

The uterus is now drawn through the ad-
dominal opening by means of a vulsellum
forceps, when by a long-bladed forceps
the right ovarian and uterine arteries are
clamped well outside the tube and ovary,
inclining the point of the forceps to the
cervix; another forceps clamps them in
the same manner close along side of the
uterus, leaving a triangular space be-
tween them. The triangular space is then
cut to its apex, and the same method is
performed on the other side.

This gives complete hamostasis for the
time. The next step is a semi-circular di-
vision (convexity upwards) of the peri-
toneum in front of the uterus, and the
same posteriorly, the cuts meeting on
each side, when it is peeled down nearly
to the cervix, catching all bleeding points.
You will observe that the patient has
been put in the Trendelenberg position
and the whole field of operation coffer-
dammed with soft towels. The next
step is the securing, with ligatures, of the
arteries which are readily seen and tied
and the two clamps removed, leaving
those on each side of the uterus. In ty-
ing the uterine arteries watch out for the
ureters in order not to include them in
the ligature, as they are very close to-
gether at this point. I had provided,
however, for this contingency when I put
on the forceps. In cutting oflf the uterus
I have made a wedge-shaped incision into
the neck, so that when it is sewed up, it
can be more accurately approximated.
You will notice that as soon as the sec-
tion was made, to prevent sepsis, we had
in readiness swabs of cottdn which were
dipped in carbolic acid and pushed into
the cervix and allowed to remain a min-
ute when a swab of cotton was dipped in
alcohol and applied to counteract the ef-
fect of the carbolic acid. All bleeding
points being secured, the wedge-shaped
incision into the cervix is approximated
with catgut, and the peritoneal flaps
which were stripped off the uterus are

caught and approximated accurately by
a continuous catgut suture (double No.
i) caught at every third stitch so as to
avoid puckering of the line of suture. Re-
moving the abdominal towels it will be
observed that we have a perfectly dry
peritoneal cavity, and that it is absolute-
ly closed off from infection below, and
now we close by layer suturing with
double-threaded catgut, not tightly
drawn, doing as was done in the periton-
eal flaps, closing the integument with a
continuous silkworm gut suture. We will
now lay open the uterus and pass it round.

You observe that the uterine wall is
much thickened and that I have made a
section through two good sized tumors,
one above the other. Their character is
so apparent that it is scarcely necessary
to have a microscopical examination to
determine them. They are undoubtedly
sub-mucous myofibroma.

These might have been romoved by
enucleation and in a younger woman I
should have made the attempt, as it is our
first duty not to destroy the child-bearing
function, but in this woman the climac-
teric period was near at hand, and at the
same time the possibility of malignancy
had to be borne in mind. While it is
true that fibroid tumors atrophy after the
menopause, I do not feel any compunc-
tions of conscience in doing what I did
in this case. I consider under the circum-
stances I did what was right, taking no
chance of future probabilities.

The case was ideal, from the fact that
the growth was not large and there were
no adesions to make the technic difficult,
and the hemorrhage was almost nil. The
tumor was a myo-fibroma (Fig. i), and
the patient made an ideal recovery.

Appendicectomy and Removal of Cyst
From Left Broad Ligament.

Case 2.

Miss S. R., aged 42 years, came from
a distance to the hospital late last night
for the purpose of having an appendicec-

WALKER

675

tomy done this morning, and I saw her
for the first time only a few minutes ago.
Her physician, however, had written mq
previously in regard to the difficulty, stat-
ing that it was chronic or intercurrent ap-
pendicitis, and that a similar diagnosis
had been made by other physicians. The
house physican, whom I requested to get
her history, informed me that she laid
more stress upon a pain that she had in

week and several other milder ones fol-
lowed of shorter duration, yet judging
from other manifestations there are other
pelvic disturbances. As she is now under
the influence of the anesthetic (chloro-
form) I make a vaginal examination and
find unmistakable evidence of a tumor,
the size of an orange, in the left side,
probably in the broad ligament. Now, as
there has been evidence of appendiceal

Fig I. Showing Section of Uterus and Hydrosalpinx.

the left side than upon the right. Ab-
dominal palpation reveals sensitiveness
in right iliac fossa at a point that might
be called the appendicial ovarian junction.
There is also more pain on pressure low
down on the left side, yet, owing to rigid-
ity over the area, it is impossible to dis-
tinguish anything positively, and as the
vagina is small, I have waited to make a
bimanual examination when she is under
the influence of the anesthetic before as-
certaining the pelvic condition.

The diagnosis is therefore still in
doubt, although she gives a history going
back nearly a year, of one marked attack
which might be appendicitis, lasting a

trouble it will be well to make a median
incision and remedy whatever trouble
may be necessary. As she is as properly
prepared as time would permit, we will
proceed with the operation. After open-
ing the abdomen I find, as I predicted, a
cyst in the broad ligament which rup-
tured as I had nearly enucleated it. Turn-
ing to the right side I find, as I bring it
out through the opening, evidence of re-
cent inflammation of the appendix and
that its tip is adherent to the right ovary.
There is also evidence of omental adhes-
ions. These adhesions are peeled off and
a purse-string suture of catgut introduced
about the base of the appendix, then

C76

SURGICAL CLINIC

cut off, treated with carbolic acid and
alcohol, stump inverted, suture tied and
reinforced with a few stitches. Cleaning
out the "pelvic box" with dry gauze, the
adbominal wound closed without drain-
age, as in the previous case.

It will seem that if I had not made
a careful examination I would have done
simply an operation for the removal of
the appendix, and left an equally import-
ant condition for some one else to dis-
cover and do another operation. In many
cases sent for operation upon the pelvic
organs, the cause is found in the ap-
pendix, and the train of symptoms that
is complained of is relieved by removing
the appendix. On the other hand, the
appendix may be only a part of the
trouble, namely, a diseased tube and
ovary, complicated with the extension ot
the trouble to the appendix. In all pelvic
operations in the female, see to it that the
appendix is healthy and whenever there
is any suspicion of involvment, remove it,
for as Dr. Price, of Philadelphia, says,
"the danger is so slight, the operation so
simple, so little time and surgery are re-
quired for the safe and clean removal of
a very common offender, that I am
strongly inclined to urge its removal in
all cases, while doing pelvic surgery."
There were no unpleasant symptoms at
any time during her convalescence, and
she left the hospital well on the twenty-
second day.

Ferguson's Method for the Radical Cure
of Inguinal Hernia.
Case 3.

N., male, laborer, aged 37 years, re-
ceived a kick from a horse eleven years
ago, which was followed by a hernia (in-
direct inguinal) for which he has worn a
truss ever since. It became partially
strangulated three weeks ago, while lift-
ing in a moving van, and was reduced
with some difficulty. As he lies upon the
operating table there is no evidence of a
hernia, but it protrudes while standing

up or with effort at coughing. The in-
guinal canal admits the index finger very
readily. About five per cent, of all peo-
ple have hernia, the larger proportion be-
ing in men. Over ninety per cent, are in-
direct, and it is estimated that one-sixth
of one per cent, of all deaths are due to
hernia. In considering the etiology of in-
guinal hernia, Marcy of Boston says that
"The principal cause is due to a deficient
fibrous aponeurosis," while Ferguson
says that "The principal predisposing
cause is a lack of complete origin of the
internal oblique muscle from Poupart's
ligament." Other predisposing causes are
heredity, long continued and wasting
diseases. The exciting causes are usually
excessive, sudden exertion or some viol-
ence, as was the cause in this case, as he
gives no evidencri of its being congenital.
His general condition is first-class, which
makes him a good subject for operation.
Dr. Ferguson noticed in doing operations
for the relief of indirect ingumal hernia
that theer was deficiency in the origin
from Poupart's ligament of the internal
oblique and transversalis muscles, and
owing to this deficiency full opportunity
was given for descent of a hern'ia through
the external ring. This condition was
proved to be correct by a series of fifty
careful dissections on cadavers, made by
Dr. R. C. Turck, of Chicago, a report of
which is found in the Journal of the Amer-
ican Medical Association, April 15, 1899.
Reasoning on this basis, he did what he
calls a "typical operation' for the restor-
ing of this deficient orgin, which I can-
not better describe than by using his own
words.

"First Step. Semi-lunar Skin Incision.
Begin the incision over Poupart's liga-
ment, one and one-half inches below the
anterior superior spinous proces of the
ilium ; extend inwards and downwards in
a semi-lunar manner, circumventing the
internal abdominal ring, and terminate it
over the conjoined tendon near the pub-

WALKER

677

lie bone. Cut carefully backwards with
a very sharp knife and expose the ves-
sels and pick them up with forceps before
severing them, and thus prevent blood-
staining of the tissues. Having passed
through the skin, two layers of superficial
fascia, fat, between them and superficial
epigastric vessels down to the aponeu-
rosis of the external oblique muscle, the
will be noticed that it is not necessary to
cut the superficial circumflex iliac, nor
the superficial pudic vessels. Take a
pledget of gauze and with it turn the flap
of skin, subjacent fat and fascia down-
wards and outwards over the thigh. This
procedure brings into view the aponeu-
rosis o fthe external oblique muscle, the
external abdominal ring, with its pillars
and intercolumnar fascia, the hernial sac,
if it has descended through the external
ring, external surface of Poupart's liga-
ment, the under surface of the flap cov-
ered by the deep layer of superficial fas-
cia, and the superficial vessels.

"Second Step. Cut through the ex-
ternal abdominal ring and intercolumnar
fascia; separate the longitudinal fibers of
the aponeurosis of the external oblique
muscle directly over the inguinal canal,
tar beyond the internal ring, over the sur-
face of the internal abdominal oblique
muscle, and up under the skin, to a point
learly opposite the anterior superior
spine of the ilium. Delicate tranverse
ibers are encountered and severed. Re-
:ract the aponeurosis of the external
Dblique muscle and thereby bring into
sight the deep structures, viz., the con-
:ents of the inguinal canal, the whole sac,
kvith its adhesions, the spermatic cord,
lio-inguinal nerve, internal abdominal
"ing usually enlarged, frequently an ac-
:umulation of subserous fat, the cremas-
:eric muscle, conjoined tendon, internal
oblique muscle, and its deficient origin at
Poupart's ligament, transversalis fascia,
md the internal surface of Poupart's liga-
ment. I consider the congenital deficient

origin of the internal oblique and trans-
versalis muscles one of the most frequent
and important causes of oblique inguinal
hernia. Inspect these structures care-
fully, and now determine whether the
operation is to be typical or atypical.
When the structures are well defined and
not too much weakened by pressure
atrophy, a typical operation can be pro-
ceeded with.

"Third Step. This step deals with the
sac and its contents ; the cord, cremas-
teric muscle, and subserous lipomata.

"Sac. The sac is carefully dissected
from the cord and internal ring; it is
always opened, contents inspected and
dealt with, and ligated high up over the
inserted finger, cut off and the stump
dropped. In atypical operations the sac
is usually preserved, as recommended by
MacEwen. If the sac be congenital, di-
vide it in two, the distal half to form a
tunic for the testicle, and the proximal
to be treated as above mentioned.

"Omentum. When omentum is within
the sac it is liberally withdrawn, tied en
masse, cut off, covered with its own
peritoneum, and returned within the ab-
domen. This decreases the intra-abdom-
inal pressure and lessens the tendency to
a return of the heria. At the stage of the
operations when the sac is opened, it is
frequently found advantageous to place
the patient in the Trendelenberg position
to prevent protrusion of and injury to the
intestines.

"Cord. The cord is not disturbed. I
have never been satisfied with the raisin^r
and transplanting of the cord. In more
cases than have been recorded the testicle
has come to grief by this unnecessary
procedure. Tearing the cord out of its
bed is without an anatomic reason to rec- •
ommend it, a physiological act to sug-
gest it, an etiologic factor in hernia, con-
genital or acquired, to indicate it, nor
brilliant surgical results to justify its con-
tinuance. Leave the cord alone, for it is

G78

SURGICAL CLINIC

the sacred highway along which travel
vital elements indispensable to the per-
petuity of our race. The veins in the cord
are not disturbed, unless a varicocele com-
plicates the hernia. If the cremasteric
fibers are unduly thickening the cord,
they had better be removed along with
adventitious tissue that is not unfrequent-
ly present.

"Lipomata. An abnormal quantity of
subserous adipose tissue is so often de-
posited around the sac and cord and along
Poupart's ligament that it is an etiologic
factor in hernia, and if it is not removed
it tends to cause a return of the hernia.
A systematic search should be made for
fatty aggregations and they should be re-
moved.

"Fourth Step. Restore the structures
to their normal positions.

"Transversalis Fascia. It forms the in-
ternal ring. In hernia its fibers have be-
come more or less stretched above and
around the cord. The ring in consequence
is abnormally large and the fascia bulges
outwards. To rectify this condition, take
up the slack in tne fascia and make an ac-
curately fitting ring for the cord by means
of a suture, interrupted or continuous.
Do not injure the deep epigastric vessels,
nor pass the needle too deeply in the di-
rection of the large iliac vessels.

"Internal Abdominal Oblique and
Transversalis Muscles. Suture these
muscles to the internal aspect of Pou-
part's ligament, and restore their normal
origin. I usually freshen the lower bor-
der of the muscles and scarify the surface
of Poupart's ligament to insure firm
union, and extend the sewing fully two-
thirds down Poupart's ligament, which
is the normal origin of this muscle in the
female. Take care not to split Poupart's
ligament by grasping with the needle the
same longitudinal libers each time. It is
surprising how easiW these two struc-
tures come together without the least dis-
cernible tension, and it is gratifying to

observe how pertfctly these powerful
muscles cover and protect the internal
abdominal ring and inguinal canal.

"Aponeurosis of the Externa^ Oblique
Muscle. Bring together the separated
edges of the aponeurosis of this muscle.
Restore the external abdominal ring.

"Flap. In bringing the skin flap into
normal position, be sure and coapt all its
structures, like to like, especially the deep
layer of the superficial fascia.

"Commendable Features, I :

"The different structures in the abdom-
inal wall are placed in their normal rela-
tionship, (i) The tying of the sac re-
stores the normal rotundity of the peri-
toneum. (2) The suturing of the trans-
versalis fascia, forming a new internal
ring, at the same time obliterates the
hernial infundabliform process. (3) Sew-
ing the internal oblique and transversalis
muscles to Poupart's ligament secures a
normal origin for them and they then
find perfect protection to the internal
ring cord and canal. (4) The suturing 01
the separated fibers of the aponeurosis of
the external oblique protects the under-
lying muscles and cord, while the skin
flap covers all.

"II. The four lines of suture are not
opposite each other, thus securing an
overlapping of the weak parts (lines of
repair) by normal tissues.

"III. The semi-lunar incision has great
advantages .(i) The hernial area is un-
covered as in no other way, thus afford-
ing its accurate observation of structural
relationship, etiologic factors and path-
ologic feactors and pathologic conditions.

(2) There is less tendency to skin infec-
tion, extending to the deeper structures.

(3) Should, unhappily, a return of the
rupture occur, there is no scar over it and
a truss can be better borne.

"IV. Of all the operations that I have
performed, it is the simplest and easiest
to execute. There is a good scientific rea-

WALKER

679

son furnished for every step in the opera- hesions, caused by the so-called injection
tion." treatment that he had received. I have

Fig. 2. Right Ovary.

Fig. 3. Left Ovary.

The separation of the sac in this case done this operation a number of times
has been difficult and tedious, owing to and although sufficient time has not
the fact that there were many old ad- elapsed since they were done to say

680

WALKER

whether a relapse may not occur, yet up
to this time there have been no recur-
rences. The method commends itself,
first as to simplicity and secondly that it
is a rational procedure as it leaves the
cord in its natural position and restores
the abdominal wall. This "typical opera-
tion" has been adopted by many sur-
geons. Patient made an uninterrupted
recovery.

Double Ovarian Cysts.

Case 4.

These specimens (Figs. 2 and 3) thai
I present to you, I removed November
29, 1902, from a woman aged 63 years,
with the following history: Mother and
two sisters died of pulmonary tuber-
culosis. She has given birth to five chil-
dren. Two are living in good health while
the others are dead. Her health has been
fair up to about ten years ago, whe she
began to complain of a heavy feeling in
the pelvic region.

A partial uterine prolapse occurred
shortly afterward. October i, she was
seen by her physician. Dr. E. R.Campbell,
of Flint, who found a complete prolapsus
uteri, which could be replaced, but which
would immediately come down again. He
was also able to diagnose that she had
large tumors on either side of the uterus,
together with a considerable accumula-
tion of fluid in the abdominal cavity. She
voided urine in the knee-chest position.
He advised operation, but she declined,
saying that she would be unable to stand
it, owing to her age and her feeble con-
dition. Dr. Campbell was called to see
her again November 18, when he found
her suffering from a localized peritonitis,
with a temperature of 102. i and a pulse
of 120, with an appreciable increase of
the fluid in the abdomen. Her condition
gradually improved in the following ten
days, so that she could be operated on.

When I saw her November 29, which
was about an hour before the operation,
I found her emaciated, but cheerful. The

prolapsus was about as cornplete as I had
ever seen. Inspection and palpation re-
vealed a well-distended abdomen, with
fluid. I had no difficulty in making out
two good-sized tumors, undoubtedly
ovarian, one in each iliac fossa. As all
preparation had been carefully made, I
immediately proceeded by making a me-
dian section, which extended from above
the umbilicus to the symphysis. The fluid
in the abdomen was dark in color and,
after letting it out, the tumors, which
proved to be large ovarian cysts, were re-
moved, together with a considerable por-
tion of the omentum, which adhered to
them. The uteris, of course, had been

^p

^HHiiMlf^

Fig. 4. Papillary Cystadenoma of Ovary
X 120.

replaced by the traction, and I fastened
it by the ligatures which were used to tie
ofT the ovarian pedicles to the recti on
each side. After mopping out all fluid
from the pelvic cavity, the abdominal
wound was closed with interrupted silk-
worm gut sutures and a gauze dainage
was introduced, simply to draw off the
ascitic fluid.

It present this cystic ovarian tumor, not
so much because there is anything out of
the ordinary in an operative way, but to
show a condition that is not common,
namely, that of cystadenoma (Fig. 4).

UREMIA

681

You will observe this papillary growth,
covering quite a considerable surface of
each cyst, and on opening the cysts it will
be seen that there is quite a similar condi-
tion growing from the inner wall of the
cyst. The omentum was studded like-
wise. Although not malignant, it is on
the borderland of malignancy, with the
possibility of recurrence.

A recent letter from Dr. C. states that
she has made an ideal recovery.

27 Adams avenue east.

Alcohol in Proprietaries. — A recent is-
sue of American Medicine quotes Dr.
Baumgartner as giving the following list
of the percentages of alcohol contained in
"patent" medicines :

Greene's Nervura 17.2

Hood's Sarsaparilla 18.8

Schenck's Seaweed Tonic 19.5

Brown's Iron Bitters 19.7

Kaufman's Sulfur Bitters 20.5

Paine's Celery Compound 21.0

Burdock Blood Bitters 25.2

Ayer's Sarsaparilla 26.2

Warner's Safe Tonic Bitters 35.7

Parker's Tonic 41.6

Hostetter's Stomach Bitters 44.3

Magnesium Dioxide in Anaemia and
Chlorosis. — A recent discovery by Dr.
Frederich Elias, of Berlin, is magnesium
dioxide (Mg O^), which, the discoverer
claims, possesses the property of giving
off large quantities of diffusible oxygen.
The fact that oxygen is found so useful
by the profession because of its important
role in the support of the system, entitles
the discovery of Dr. Elias to a trial at the
hands of physicians. The discoverer has
named his new product biogen, and the
preparation is used successfully in those
forms of disease characterized by lack of
oxygen, by alteration of the blood com-
ponents. For this reason it is used with
particular success in diseases like anaemia
and chlorosis.

UREMIA: A RESUME OF THEORIES

AND RESEARCH.*

BY HOMER E. SAFFORD, M. D.,
Detroit, Mich.

Much has been written and many ideas
held of the essential features of the ure-
mic process, but it is only the more self-
assured among the investigators who
have thus far been willing to make posi-
tive assertions on the main point at issue,
viz., what may we conclude are the causes
of uremia in the ordinary acceptance of
the word? Some have gone a long way
around to end with the statement that
this or that poison or process was not the
cause, while this or that might be; and
then the next writer has overturned the
whole hypothesis.

Putting: aside for the moment the ques-
tion of ultimate cause, we may properly
ask the investigators, "What is uremia?"
In reply we should find an agreement
that it is a train of symptoms mainly
nervous in character, but the immediate
action upon the nervous structures is a
very unsettled question in the minds of
those best qualified to express an opinion.
Traube, for instance, saw in the process
simply an cedema and an anemia. The
oedema was itself induced by a failure of
the kidney to excrete water, leading thus
to a thinning of the blood. This, by in-
creasing blood-pressure, threw extra
work upon the' heart and so came the ex-
udation into the tissues. The pressure
of this exudation upon the vascular chan-
nels cut off nutrition and thus anemia
became the natural result of a process up
to this point a purely mechanical one, fol-
lowing upon the affection of the kidney.
It is practically needless to discuss this
conception except to dismiss it ; for the
demoi '-:ii-r;-. -s easy that neither the
cedema nor the nephritis nor the high ten-
sion nor the low specific gravity of the
blood is, any one of them, an absolute
essential of the uremic state. A more ac-

•Read before the Pathological Club, December
16th, 1902,

682

SAFFORD

ceptable modification of the explanation
by oedema is that of the pressure of fluid
upon the centres along the cerebro-spinal
axis, induced by, or at least accompanied
by, a more important element, the tox-
emia. Here, however, we are again at a
point of division, for almost every con-
stituent of the urine and the blood has,
by increase or decrease, been held to pre-
sent the essentially disturbed function.
In fact we may, almost without hesita-
tion, say that the battle royal of the whole
controversy has been for sixty years and
is still waged over the relation of the sub-
stance urea to the toxemia presented. A
large majority of investigators would per-
haps admit at once the "retained urinary
products" as the direct cause, or at least
the manifest starting-point, of uremia,
since this would include many of those
both for and against urea in that connec-
tion; but another bone of contention
arises in the word, retained, some of the
latest experimentation being directed to
the proof that not so much the mere re-
tention as an enormously increased elab-
oration of poisons comes into play as an
essential feature ; in other words, the pro-
cess is, according to this idea, to be con-
sidered primarily a disorder of metabol-
ism. Just here we find those who, ac-
cepting the theory of disturbed metabol-
ism, attempt to explain it further by the
hypothetical disturbance of a hypotheti-
cal internal renal secretion, as suggested
by Brown-Sequard. Again we find the
claim that the metabolic product causing
the symptoms of uremia is an albuminous
body circulating in the blood of those
with uremia, previously unrecognized.
Finally it should be mentioned that von
Jaksch and Von Limbeck brlicvc -l-at the
process starts in an alteration oi ilie al-
kalinity of the blood.

This glance over the field gives us at
the start an idea of how far we are from
being able to fall back upon any "con-
sensus of the competent"; and perhaps

the best service I can render will be to
run over, as briefly as may be, the evi-
dence in favor of some of the more plaus-
ible explanations and bring together what
we may feel some assurance of having
demonstrated as fact, while pointing out
the trend of the less certain but useful
speculative thought. Much is written
which the verdict of scientific criticism
will not value greatly, and some efforts
at the solution of the problem are little
more than amusing. As an example of
the latter class, I would refer to an article
in the Medical Record of September ist,

1900, entitled "The Discovery of Ureine,
the True Cause of Uremia." This article
read in connection with its scientific crit-
icism by Dr. Weatherson in the Journal
of the American Medical Association for

1901, gives one a comforting assurance
that truth in scientific investigation will
prevail. We can not all do the necessary
experimentation nor observe the neces-
sary abundance of clinical cases that will,
I trust, in time settle this difficult prob-
lem, but we may well acquaint ourselves
with the material presented and the crit-
icisms passed upon it.

Among the earliest efforts to account
for the symptoms of uremia on the
ground of a toxemia is that quoted by
Bright in 1840 as the work of Bostock.
Statements were made about the same
time by Christison and others to the et-
fect that urea was specifically accounta-
ble; its presence in the blood in increased
amounts had been determined, and some-
thing had been done to observe its effect
upon animals as early as 1822, but noth-
ing in these early experiments had been
done to prevent elimination. About 1865
Frerichs went over the subject and de-
nied the possibility of urea being the
cause of uremia because, he said, urea did
not induce in animals the symptoms of
uremia as some had claimed. He ad-
vanced the theory that ammonium carbo-
nate was the active cause, but this idea

UREMIA

683

was abandoned when others attempted
its confirmation.

Owen Rees showed that anuria and a
large urea-content in the blood of a pa-
tient had failed to induce the symptoms
of uremia. Oppler held that it was un-
likely that urea or any other urinary con-
stituent should of itself act as a blood
poison. He maintained that, through
some interference with the function of ex-
cretion, the metabolism of the tissues all
through the body was altered and their
nutrition so affected as to cause the
symptoms. This view is elaborated in
its main contention by Bradford in the
Goulstonian Lectures for 1898. To the
details of this report, I shall beg leave to
refer later at some length. I wish first
however, to refer to the work of some
others of the recent investigators, nota-
bly that of Hughes and Carter, published
as the Boylston Prrize Essay for 1893 in
the American Journal of Medical Sciences
for the following year, and also the essay
of Herter as one of the contributions em-
braced in the Welch Festschrift at Johns
Hopkins University in 1900. Of others
I will make but passing mention.

Hughes and Carter, working at the
University of Pennsylvania, started out
to demonstrate the effect of the injection
of blood-serum from uremic and other
patients into animals and to compare with
the effects obtained that following the
similar injection of a blood-serum from
a dog in which the renal arteries had been
ligated. Blood-serum from a uremic pa-
tient was found to be pathogenic to dogs
and fatal if in considerable doses. The
same was observed in the use of the as-
citic fluid during the uremic attack, but
the fact is also interesting that, after the
attack of uremia has passed, the ascitic
fluid does not induce uremic symptoms.
In all these experiments, vomiting ana
purging were regularly observed, and
often coma and occasionally convulsions
were seen. In the cases in which, in dogs,

the renal arteries were tied the symptoms
reported were almost identical witn tiiosc
above described; convulsions, however,
appeared but once. With the blood from
such dogs, the serum induced symptoms
much the same, though less pronounced.
The serum from both the uremic patients
and the dogs operated upon was subject-
ed to the action of heat. Apparently the
active principle was rendered inert by a
temperature of 55.-58. C, continued from
5 to 10 minutes. When placed in a dialy-
zer with distilled water, it was found tnat
the water passing through the dialyzing
membrane did not contain the active
principle to any considerable degree, al-
though the remaining fluid within the
dialyzer remained distinctly pathogenic.
In concluding their reports, Hughes
and Carter ask, "What then is the nature
of this uremia-producing poison? That
we have been dealing with one poison,
present equally in uremic human blood,
in dropsical effusions in uremia, and in
dogs' blood in experimental uremia, is
made evident by the perfect similarity of
its action. That this poison cannot be
one of the ordinarily recognized constit-
uents of the urine, as has been hitherto
believed, nor the sum total of all these
urinary constituents is proven by the
fact, which we have demonstrated, that
the injection of these constituents or even
of urine itself will not produce uremia.
While such injections, if the amount used
be inordinately large, will produce cer-
tain symptoms, yet these symptoms are
not comparable in degree or kind with
those produced by the injection of uremic
serum, and they do not constitute the
condition which we recognize in man as
uremia. Thus we have to deal in uremia
not with an intoxication due to a reten-
tion of urine or its constituents in the
blood, but with a poisoning by a sub-
stance whose nature, or, indeed, whose
very existence has not been recognized.
A clinical proof of this fact is the possi-

684

SAFFORD

bility of the existence of uremia while
there is no demonstrable evidence of dis-
ease in the kidneys and normal amounts
of normal urine are being secreted.
While, however, the retention in the
blood of substances ordinarily recognized
as bemg excreted in the urine is not the
cause of uremia, yet, after uremia has
been produced, such retention may in all
probability have a certain effect, aggra-
vating the already existing condition or
determining its variety. The poison
then must be a special one circulating in
the blood under conditions which are not
governed wholly by the action of the kid-
neys as it is evidenced in the urine. As
to its exact nature, the facts that we have
ascertained positively are that its uremia-
producing power is rendered abortive, or
at least much lessened, by the moderate
application of heat and that the active
principle is not readily dialyzable."

It may be well to mention here the
notable effort of Bouchard to discrimi-
nate between the seven poisons, or "uro-
toxins", which he claimed to have isolated
from the urine of uremic patients. He
defined them respectively as a diuretic, a
narcotic, a sialagogue, a myotic, a tem-
perature-reducing principle, and two con-
vulsants. In general he supported the
theory of retained urinary products as the
source of uremic symptoms; but his de-
tailed scheme of specific toxic constitu-
ents has not borne confirmation.

In the line of research upon the toxi-
city of urine, one of the most interesting
points has been that upon the freezing-
points of urine and of blood in uremic
conditions. Richter and Roth noted the
molecular concentration of the blood at-
tending double nephrectomy, while re-
moval of one kidney did not have this
effect. (Compare Bradford's work.) In-
jury of the remaining kidney, after re-
moval of the first, leads to excessive mole-
cular concentration. Koranyi, also in-
vestigating the freezing-point, concluded

that the metabolism of the porteids pro-
duced the poisons of uremia. Lindemann
reported that, in uremia, the freezing-
point of blood is much depressed. Koevesi
and Roth-Schultz speak of molecular
oliguria, with high freezing-point, in ad-
vanced nephritis. They lay down the
rule that "the determination of the freez-
ing-point of the urine and the quantity of
the urine excreted in a day shows wheth-
er there is molecular oliguria and a deter-
mination of the freezing-point of the
blood shows whether the kidneys are re-
moving waste products properly." I note
these conclusions for the bearing they
have upon some of the evidence pre-
sented by others.

In the work of Bradford, to which I
have referred, the main contention cen-
tres in the claim that the kidney " in
some way influences the metabolism of
the tissues, so that, if the quantity of kid-
ney substance present is greatly reduced,
the proteid tissues and more especially
the muscles break down and liberate urea.
This view", he says, "is based upon the
following experimental facts: (i) Wherf
the amount of kidney is reduced to one-
quarter of the original total kidney-
weight, the quantity of urea excreted in
the urine is increased ; (2) The amount
of urea in the blood is greatly increased
at a time when this increased excretion
of urea is going on. (3) There is great
emaciation, even if the appetite is main-
tained and the emaciation cannot be ar-
rested by the most abundant diet. (4) If
the appetite be completely lost and no
food be taken, the amount of urea in the
urine may remain at a level as high as
that at which it stood when the normal
animal was eating freely and maintain-
ing its body-weight." He remarks that
such facts would make one turn to the
theory of an internal renal secretion, the
disturbance of which might lead to the
disorder of metabolism, but he interprets
the results of some of his experiments as

UREMIA

685

distinctly against that hypothesis. Furth-
er than this he does not attempt to go in
explaining just what is the medium for
the renal influence upon tissue metabol-
ism. Some of his experiments are upon
the effects of partial nephrectomy, in
which a part of one kidney and the whole
of the other were removed; in others
double nephrectomy or ligature of both
ureters was performed; and finally he
studied the effects of the intravenous in-
jection of urea. Besides this experimen-
tal work, the observations upon a series
Df clinical cases are interpreted.

In the partial nephrectomy cases it
was determined that when the total re-
maining kidney tissue equalled but one-
third of the normal ^.J grams per kilo of
body-weight, the dog would live and en-
joy good health ; the operations were well
borne and the recovery was almost in-
v^ariable. With two-thirds or less of to-
tal kidney-weight thus removed, the urea
in blood and urine was not materially
increased in total amount but the amount
3f water was not materially increased in
total amount but the amount of water
used in excretion was vastly augmented,
rhe hydruria was not, however, attended
by any of the more pronounced effects
iccompanying the removal of three-
[juarters or more of the total kidney-
weight. The latter were essentially
t'atal, and between the two-thirds and the
three-quarters limits lay the transition
from health to a condition terminating
iatally. In no case, he insists, even where
Duly a tenth of total kidney-weight re-
mained intact, was there a failure to ex-
:rete urine with abundant quantities of
Lirea. In cases with one-third remaining,
the only symptom to be thought of in
connection with uremia was a fall in
body-temperature and occasionally a di-
arrhoea ; no vomiting, convulsions, coma,
nor dyspnoea. Occasionally an increase
in urea-excretion was observed. In the
fatal cases, with more than three-quar-

ters removed, the urea-content of the
blood was greatly increased, even to
twenty times the normal amount. Even
more striking is the proportion of extrac-
tives found in the tissues, especially the
muscles, where there is not only a large
amount of urea but also a vast increase
in those extractives, insoluble in abso-
lute alcohol but soluble in rectified alco-
hol, belonging to the creatin class. This
in the experiments upon double nephrec-
tomy also is a point upon which the au-
thor lays great stress, as bearing out his
idea that metabolism, especially in the
muscles, is affected directly by a dis-
turbance of the kidney's function. In the
other experiments, where varying quanti-
ties of urea were injected intravenously,
there occurred at times equally large
amounts of urea in the blood itself, but
the amount in the tissues of muscles,
liver, and brain were invariably less,
while the great increase of the other
muscle-extractives was notably absent.

In speaking of com.plete nephrectomy,
the author says that "dogs lived from
three to five days. During the first two
days there was little to note except lack
of appetite. Muscular weakness, begin-
ning on the second day, is progressive.
The most marked feature, aside from
weakness and wasting, is the decline in
bodily temperature. The fall is contin-
uous and progressive. There may be
slight drowsiness, but in none of these
experiments was there anything ap-
proaching coma. Vomiting and dyspnoea
were not conspicuous and convulsions
were not observed at all."

With ligature of both ureters there was
essentially the same picture as that fol-
lowing complete nephrectomy. There is
invariably a hydronephrosis induced, a
condition peculiar in that it differs from
that accompanying calculous obstruction
in man, where complete or nearly com-
plete suppression is the rule. The same
condition exists here as with double

686

SAFFORD

nephrectomy with regard to the increas-
ed proportion of extractives in the mus-
cles, liver, and brain.

The clinical cases reported embrace
five of complete suppression, and the du-
ration of life, together with the urea-con-
tent of the blood, makes an interesting
comparison when taken with the results
obtained from the animal experiments.
Three were cases of simple calculous sup-
pression which lived 5, 6, and 9 days re-
spectively and gave urea values of 0.277,
0.324, and 0.44 per cent. Another whicn
lived 7 days showed a percentage of 0.36
and post mortem was found to present
an endarteritis and thrombosis involving
almost or quite the whole kidney cortex.
The fifth was one in which the kidney
itself presented no lesion, but an inflamed
sacculus in the bladder was the apparent
cause by purely reflex process. To me:
this is of striking interest, as suggesting
the possibility that even relatively, if not
indeed perfectly, healthy kidneys may rc-
flexly become the cause of the most pro-
found toxic effects. Of this possibility,
I shall wish to speak at greater length in
connection with some of Herter's experi-
ments. Bradford is pleased to speak of
these five cases as varying types of "la-
tent uremia", the symptoms of which are
essentially those described by Sir Wil-
liam Roberts as following ordinary ob-
structive suppression in each instance
and are strikingly comparable to those
presented by nephrectomized dogs.
"There were consciousness, myosis, fall of
temperature, occasional vomiting, and to-
ward the end slight and rare twhchings
of the voluntary muscles, and perhaps
slight drowsiness, but no coma, convul-
sions, nor dyspnoea." The author's com-
ment is, "I think we must conclude that
complete suppression, of sudden origin
and dependent upon obstruction of the
ureters or upon certain acute lesions of
the kidney causing entire cessation of the
rcsAl actirities (such as the cases de-

scribed above) does not produce acute
uremia."

"True acute uremia I have not been
able to produce in the laboratory. . . .
Acute suppression is rare in chronic
Bright's disease and certainly acute and
rapidly fatal uremia may occur in this
form of the disease whilst the patient is
passing: quite considerable quantities of
urea and urine."

In devoloping his theory of uremia,
Bradford asks, "Are the toxic substances
involved the products of normal metabol-
ism and toxic only by retention, or is
there an abnormal metabolism? I think
a consideration of the facts, experimental
and clinical, that have been adduced will
show that uremia cannot be explained on
the hypothesis of the retention of either
one or many or all of the urinary con-
stituents, products derived from a normal
metabolism. The sudden and complete
suppression of the functions of kidneys
up- to that time healthy produces a train
of symptoms similar to those seen in ob-
structive suppression and, as already in-
sisted on, a group of symptoms resemb-
ling only very distantly those of acute
uremia. . . . Formerly it was thought
that non-obstructive suppression certain-
ly caused uremia. . . . The main con-
clusion that I hope to have established is
that, both in the laboratory and in dis-
ease, the suppression of the activity of
kidneys up to that time healthy fails to
produce acute uremia. . . . The reten-
tion theory is, I venture to think, inade-
quate and it is to me probable that there
is an abnormal product of a disordered
metabolism. Experimental evidence
points to the conclusion that the kidneys
in some way control the metabolism of
the bodily tissues. The increased pro-
duction of nitrogenous extractives in the
tissues cannot be explained by mere re-
tention."

The work of Herter on the relation of
urea to the existence of uremia take* up

UREMIA

687

the consideration of its relations to physi-
olog-ical excretion as well. His reports,
like those of Bradford, enter into minut-
est detail, as no others I have mentioned
have done, of the urea-content of the
blood. A considerable discrepancy seems
to appear between what these two inves-
tigators consider normal to human blood,
Herter gives as the limits o.oi to 0.06 per
cent, and says that values usually fall be-
tween 0.025 and 0.045 P^r cent. Bradi
ford gives 0.015 to 0.02 per cent, as the
average and Simon's "Clinical Diagno-
sis" gives approximately this lower value.
This discrepancy is of some importance
in the consideration of certain cases ap-
proaching the abnormal. The conditions
under which Herter established his nor-
mal average, viz., "healthy young men
and patients, at Craig Colony", may ac-
count in a measure for this discrepancy.

In chronic conditions of the kidney,
Herter's report includes many cases in
which the urea-content in Lbe blood
ranges from three or four to twenty
times the normal. Of these cases he
says, "It is a striking fact that so large a
proportion of cases of chronic nephritis
show a distinctly excessive urea-content.
Often it has been observed in persons
who had had no acute exacerbation of
nephritis. Probably in such cases it was
a gradual development, appearing long
after the first structural change. In such
patients, the urea-content probably fluc-
tuates before the stage is reached when
the percentage is continuously or uni-
formly high." Herter's idea is that the
accumulated urea may intermittently
serve as its own diuretic.

He then proceeds to divide his cases of
acute and chronic nephritis according to
the urea-content in each, making three
classes. In those below 0,1 per cent.,
there are ten cases observed and these
include two which developed symptoms
of uremia. In those with urea-content
between o.i and 0.3 per cent., he finds

twenty-four cases and among these were
ten undoubted cases of uremia and eight
others which had symptoms like those of
uremia but had other possible conditions
to which these symptoms might be re-
ferred. In the class embracing those
with urea-content above 0.3 per cent.,
there were seven cases, of which four
were "well-developed and unequivocal
forms of uremic intoxication." In no
one were marked cerebral symptoms ab-
sent.

On the basis of these observations
Herter concludes, "There can be no
doubt that the observations included in
these three groups justify the inference
that unequivocal symptoms of uremia are
very much more common in those cases
of nephritis in which the urea-content of
the blood is excessive than in those
where it is either normal or only moder-
ately increased. They also point to an
important conclusion as regards the
probability of a fatal issue. It can be
stated that a patient is in grave danger
of developing unequivocal symptoms of
uremia (convulsions, dyspnoea, vomiting,
diarrhoea) whenever the urea-content of
the blood increases beyond 0.2 per cent,
and that a fatal issue is almost certain to
occur within a few weeks in a patient in
whom the urea-content of the blood

amounts to more than 0.3 per cent

But although it is a fact that the liability
to uremic symptoms increases with the
augmentation in the urea-content in the
blood, this is far from being proof that
the excess of urea is in reality the ef-
fective cause of these symptoms. To
prove this it would be necessary to show
that the blood of our uremic patients con-
tains no other bodies capable of giring
rise to the intoxication in question and
such a demonstration is not practicable.
. . . Different types of uremia exist
and we must clearly distinguish between
these in any discussion of the role played
by pathological accumulationa of *irc*.

688

SAFFORD

The uremia that occurs in the course of
acute infectious diseases in persons with
previously normal or presumably normal
kidneys must not be confounded with
those examples of uremic intoxication
that develop in the course of a chronic
nephritis." -Here he believes we see the
gradual development of the renal insuf-
ficiency for area, reaching a high grade
and inducing uremic symptoms with very
little elevation of temperature. Such
cases he says "we may safely assume"
are due to retained urinary constituents.
Of disordered metabolism and its pro-
ducts, our ideas are he thinks "unsup-
ported by substantial evidence". Finally
with reference to the effect of urea upon
dogs, he concludes in brief that "these
considerations render it in the highest
degree probable that urea plays a part,
and a leading part, in bringing on uremic
symptoms in certain patients with chron-
ic nephritis".

In Herter's consideration of the physi-
ological relations of urea, an interestn g
comparison is drawn between Vvhat vve
may call the elasticity of the kidney's
function in the higher animals and in
the frog, in which the lower type of de-
velopment of the organ persists. He con-
cludes that the functional effectiveness
of the mammalian kidney is at least
twelve times that of the Wolffian body
of the frog, weight for weight. In ex-
periments with animals on the effects of
urea injected in solutions of varying
strength and quantity it was determined
that in all forms of kidney it was possible
to find a strength of solution and rate ot
injection above or below which diuresis
was not so easily established nor so well
maintained. In the normal animal, how-
ever, the limits for this action were quite
elastic. It was shown that in kidneys
previously subjected to the action of can-
tharidin the nephritis induced led to a
peculiar effect upon the limits of renal
sufficiency. A strength and rate of in-

jection that in health would have increas-
ed excretion actually decreased it or prac-
tically caused suppression. If, then, a
weaker solution were first injected and
more slowly, the kidney could, for a
time, be nursed back almost to its normal
maximum efficiency. Although the au-
thor does not dwell at length upon this
point, it seems to me to be of the utmost
importance in any attempt to understand
the whole picture of the uremic process.
This stammering, as we may call it (This
term is applied by Paget to a reflex dis-
turbance at the bladder neck that may
be considered remotely analogous) seems
to me to express the state of a kidney
in which, under violent reflex or direct
irritation, it refuses to function. What
happens afterward may be conceived of
as a reverberation of progressively in-
creasing ill-effects between the kidney in
this state of hesitancy and the tissues,
whose disordered metabolism becomes
thus alternately cause and effect. I do
not say that this leads us to the ultimate
cause of uremia, for that, as I have indi-
cated, may be manifold in character ; but.
granting that the reflex mechanism in-
volved in the renal activity can be so dis-
turbed that for instance the blood-supply
can practically be cut off or the secreting
epithelium made unable to regenerate by
virtue of some form of depression, do we
not see that practically any kidney is po-
tentially in a condition to become a me-
dium for the induction of uremia? Does
not this conception help to harmonize
those cases of uremia which we know as
puerperal eclampsia and in which there
may be no demonstrable increase in the
urea-content of the blood with the more
common type as it accompanies the vari-
ous forms of Bright's disease? It is only
necessary to admit, as most investigators
seem ready to do, that urea is not at
least the only poison which can induce
this train of symptoms to have completed
a conception more satisfying than most

SAFFORD

689

such theories, taken by themselves, have
become in the light of all the facts.

Let me refer again to Herter's experi-
ments more in particular. In the case of
dogs injected by the femoral vein with
solutions of urea, the maximum secre-
tion and one that could be maintained
for hours without apparent injury was
with a 4 per cent, solution infused at the
rate of 5 c. c. per minute. This would
seem to be the maximum normal capacity
(about twenty times the normal demands
made upon the animal's kidney) for rea-
sonably prolonged periods. That the or-
gan should become exhausted in time
under this strain of work is natural to
expect and was indeed indicated by the
condition reported histologically. There
were oedematous and granular appear-
ances in many cells, but an unaltered nu-
cleus indicated the possibility of regener-
ation. Very different was it when, with
the rapid injection of more concentrated
solutions, the evidence was that of an ac-
tually damaged epithelium, giving such
an appearance as to show a loss of struc-
ture in the cytoplasm and even a frag-
mentation of the cells in certain tubules.

Where the avenues of excretion are cue
off in dogs, death will ordinarily not su-
pervene until nearly i. per cent, of the
body-weight of urea is infused, whether
introduced slowly or rapidly; "where
urea is infused so rapidly as to cause
death in one to tivo hours, it makes little
difference in the fatal dose whether the
kidneys be permitted to act or not" (Her-
ter). Would it here be unwarranted to
suppose that, under the toxic effect of the
urea, the kidney-cells individually as well
as the vascular structures of the organ
collectively underwent a spasmodic re-
action, in the latter vaso-motor, in the
former a trophic disturbance? The rela-
tion of the one of these processes to the
other it need hardly be necessary to con-
sider for our present purposes. In the
application of the general idea which I

have suggested, may we not conceive
that this spasmodic, revulsive action of
the kidney, rarely as a whole in health,
more frequently in its relatively healthy
portions left functioning after previous
disease, follows when, as I have indicat-
ed, it is confronted with a direct irrita-
tion entering by way of its blood-supply
or borne to it reflexly with its vaso-motor
or trophic impulses.

Herter calls attention in detail to some
fourteen cases of fatal acute lobar pneu-
monia in which the end presented the
symptoms of an acute uremia and an ob-
servation of the blood revealed the pres-
ence of from five to fifty times the normal
amount of urea in circulation. Granting
that the urea in these cases was an ag-
gravation of the trouble, it seems reason-
able that the beginning of the end was
when the kidney suddenly refused to do
what the storm of specific poison thrown
upon it made reflexly impossible. When
we understand this condition, our treat-
ment will aim at exactly what I believe
we accomplish by saline infusion in such
cases at present, viz., nursing back, or
coaxing, the kidney to do what it refuses
to be forced to do.

I realize that such a conception has lit-
tle definite evidence experimentally to
support it, but it seems to me to present
a portion at least, not previously insisted
upon, of any hypothesis that shall formu-
late, from clinical and experimental ob-
servations, a true picture of the condition
and process now so indefinitely under-
stood as uremia.

S96 Woodward Avenue.

Health In Islands. — It has been fre-
quently observed that the inhabitants of
islands and small peninsulas attain long-
er life than those of continents. The
Barbadoes, Greece, Madeira and the
Shetlands are quoted as illustrations of
the truth of this statement. — {Medical
News.)

C90

RECURRING TONSILLITIS

RECURRING TONSILLITIS.*

BY JNO. A. DONOVAN, M. D.,
Butte, Montana.

In selecting this for my subject, I am
led by the fact demonstrated by my daily
practice that, though for the past two
or three years the tonsils have been most
carefully studied and discussed by laryn-
gologists, it is evident the general practi-
tioner has given it no attention. I find,
with very few exceptions, that unless the
tonsil is decidedly hypertrophied it has
been considered normal. I shall confine
my remarks to what I consider the most
practical points, doing so in the briefest
manner possible, that more interest may
be taken in this class of suffering pati-
ents.

We have the faucial, pharyngeal, lin-
gual and eustachian or tubal tonsils. I
shall consider only the faucial. They may
be tersely described as almond-shaped
bodies of lymphoid tissue or conglomer-
ation of Peyer's patches. The depres-
sions number from lo to 20 and consti-
tute the crypts or lacunae of the tonsils;
normal size is about one-half inch long by
©ne-third inch thick. Weight, 2 drachms.
They are situated between the anterior
and posterior pillars of the fauces. By
drawing the anterior pillar forward, out-
ward and slightly downward, the plica
trianguj: ris will be seen extending from
its edge downward and backward to the
tonsil. Above this is a triangular space,
tnc supratonsilar fossa. It extends in-
ward, upward and outward into the soft
Valate, downward and anteriorly between
the tonsil and the plica triangularis, send-
ing a prolongation downward behind the
tonsil. Note what an ideal cavity for the
retention of culture media, with resulting
formation of peritonsillar abscess.

External to the tonsils is a strong
fibrous membrane, and outside of this the
superior constrictor muscle. The large
vessels lie immediately external to this

Re«d before the Silver B«w Medical Society, D«-
«k(nber 24. 1902.

and about 15 to 20 'mm. behind the pos-
terior edge.

The location from outside may be
given as a point midway between the
angle jaw and anterior border of the
sterno mastoid muscle and the tip of thfc
hyoid bone.

Arterial supply from facial through its
tonsillar and palatine branches, from the
lingual and the ascending pharyngeal.

Nerves — Glossa pharyngeal, tri-facial
and sympathetic.

Lymphatics — Superficial and deep,
passing into upper carotid cervical
glands.

A clear idea of these anatomical rela-
tions is essential to comprehend the clin-
ical significance of symptoms produced
by pathological conditions.

Function — This has been discussed by
many authors, with entirely different
conclusions. I quote the conclusion of J.
Uhlman, Medical Nezus, Jan. 26, '01. "The
normal tonsil has a physiological func-
tion, probably protective to the organism.

(2) That being in itself often diseased,
the physiological function of the tonsil is
impaired, and that instead of being pro-
tective, it is the nidus for the growth and
distribution of pathogenic organisms and
their poisonous products in the system.

(3) That many grave and fatal genera)
infections have their origin in the tonsils.

(4) That if the exanthemata, particularly
scarlatina are of bacterial origin, the
tonsil acts in part as a port of entry. (5)
That acute articular rheumatism, and the
diseases often associated with it, endo-
carditis and chorea, in the great majority
of cases, are due to the action of attenu-
ated bacteria, their toxins, or both, enter-
ing the system through the diseased ton-
sil. (6) That in those rare cases of
typhoid fever in which no intestinal
lesions can be demonstrated, the similar-
ity of the tonsillar tissue and Peyer's
patches suggests the tonsil as the port of
entry of Eberth's bacillus. (7) fhzt

DONOVAN

691

scrofulosis is often associated with dis-
eased tonsillar tissue, and that the tub-
ercle bacilli often enter the system via
the tonsils. (8) That the tonsil is too
little examined at autopsy, and much
light might be shed on fevers of uncer-
tain origin by its bacteriologic and his-
tologic examination."

Pathological tonsils may be classified
as interstitial or sclerotic, resulting from
slow or recurring inflammation. The
lymphoid — a simple hypertrophy of
otherwise normal structure in early life,
but assuming other types as age ad-
vances. Lacunar or cryptic or honeycomb
walls of the lacunae undergo change. A
desquamation and accumulation of dead
cells may distend the lumen with plugs.
These may become horny, fatty, caseous
or calcified. It is with this variety we
have the repeated sore throat, sharp
pains, expulsion of cheesy plugs with the
pungent odor of putrefaction, followed
by relief till they fill up again.

Any abnormal condition of these lac-
unae or hypertrophy of tonsil, or ad-
hesion of tonsil with the pillars may form
an ideal trap for specks of food, exfoliated
epithelium, glandular secretions, etc.
These with the germs always present may
produce the most serious results.

The most prevalent mistake made is
that the tonsil must be enlarged to re-
quire attention, while any of the above
conditions may produce the most annoy-
ing disturbances entirely independent of
the size of the tonsil. Pynchon has called
attention to the many annoying symp-
toms caused by what he names the sub-
merged tonsil. The symptoms indicative
of diseased tonsils are frequently: —
cough, especially on retiring (this may
often be produced by putting the probe
point into a diseased crypt), uncomfortable
deglutition, impaired hearing, smell and
taste, subjective sensations in the throat
pains, glandular enlargement, voice
chaajed and easily exhausted, otitis, neu-

ralgias, etc. The small obstructed lacunae
are more trouble usually than those with
open crypts.

The sequelae, besides the complications
following sore throat, tonsillar abscesS;
etc., with which you are all familiar, are:
enlarged and suppurative glands, septic
infection, septicaemia, endocarditis (unfor-
tunately, is not extremely rare), pneu-
monia, typhoid and tuberculosis, un-
doubtedly from lodgement of specific in-
fective material. Several cases of septic
phlebitis have been known to follow. I
had one case of pneumonia follow an
acute peritonsilar abscess, and with one
patient who had retention of pus for
some time in an atrophied tonsil, in spite
of radical treatment, her cervical glands
became enlarged, goitre followed, with
more glandular envolvement and death.
In these patients I felt positive that the
tonsils were the direct cause of infec-
tion.

Treatment: As you will most likely
first see these patients in the inflamma-
tory or suppurative stage, immediate ac-
tion is necessary. A few words on dif-
ferentiation are essential. There may ex-
ist a genuine tonsillar abscess; swelling,
confined to the tonsil and mouth ; it is
freely opened with little pain. Abscess
in anterior pillar usually results from a
tooth or foreign body; swelling anterior
to tonsil ; mouth may be opened, but pain-
ful. Peritonsillar abscess or a supra-
tonsillar phlegmon is the most common ;
general swelling, extreme pain and mouth
opened with extreme difficulty.

In all cases elimination is indicated;
for this calomel and phosphate of soda
are preferable. Benzoate of soda, salicy-
lates, guaiacol, etc., have their special in-
dications. Local application of 40 per
cent, silver nitrate or 50 per cent, guaiacal
solution will frequently abort.

When suppuration has taken place,
under no conditions should you allow it
to remain, as the complications resulting

692

RECURRING TONSILLITIS

from confined pus in a gland, so intimate-
ly connected with the lymphatics, are too
serious to ever be overlooked, besides its
liability to rupture in the night, causing
suffocation ; or it may burrow downward
or produce erosion of the large arteries
with fatal results. In peritonsillar ab-
scess, the incision should be made in the
supratonsillar fossa, at the same time see-
ing that the mouth of this space is freely
open. A special shaped knife is neces-
sary for this. N. R. Pierce, of Chicago,
has devised a special knife and dissector
to work in this space. I use a sickle-
shaped knife and split the tonsil down-
Nward. In this condition many still prac-
tice opening through th eanterior pillar,
•or into the soft palate, preferably one-
fourth inch above the palatine arch and
at right angles to it with a straight knife.
By this method of incision the edges will
be kept apart. Should this method be
found necessary, it should still be follow-
ed by free opening in the supratonsillar
fossa; results are more satisfactory and
recurrence not probable. Myles' tonsil
punch will often be found of value for
this.

In many cases of recurring tonsillitis,
during the intermission they are so con-
tracted as to be difficult to remove; it is
therefore, frequently advisable to en-
courage an acute attack and remove dur-
ing height of swelling. Thus you re-
move much more tissue, while the danger
of infection is, in my opinion, no greater
than by simply opening the tonsil. 1
have performed tonsillotomy, but in get-
ting pus cut out the superior part of the
remaining portion with Myles' punch for-
ceps, allowing pus to freely escape from
a very open mouth. This practically
eliminates chances for recurrence.

There is still much discussion as to
whether the tonsillotomy or tonsillect-
omy should be done, though the majority
adhere to the former (partial removal).
J. H. Coulter gives the following reasons
for tonsillectomy :

"(i) It gives a cosmetically perfect
throat, free from liability to absorb tox-
ines, etc.

"(2) Liberates and gives perfect ac-
tion to the pillars.

"(3) Removes mechanical obstruction
to sound waves.

"(4) Relieves reflex disturbances.

"(5) Leaves perfectly smooth sur-
faces.

"(6) If pillars are previously hyper-
trophied they become normal."

In the cryptic variety, each lacuna
should be opened and cauterized with
electro-cautery preferably, through gua-
iacol, silver, etc., may be used. In many
patients this method of treatment must
be followed. It requires many sittings
to complete it, as but few are treated at
a time. The more I treat in this manner,
the more convinced I have become that
if the patient would consent, the whole
tonsil can be removed with as little pain
or less than the treating of a single crypt.
The trouble in removing is to cut deep
enough to get at the bottom of each crypt
in removing it. Sometimes the removal
of the upper portion with a punch forceps
will suffice, though I have within the past
week been obliged to remove the re-
mainder in two patients because the
above operation had failed to cure.

The otherwise admirable Matthew's
tonsillotome when used alone on these
contracted tonsils is useless. A tonsil-
lotome may be used if all adhesions are
first divided; the tonsil then drawn well
out with a specially devised tonsil forcep,
and cut off at its base. There are many
ways advocated for their removal. Cau-
tery puncture or dissection with cautery
requires repeated sittings. In some I use
the snare ; when it can be used, the tonsil
snare is one of the safest procedures.
Some I cut out piecemeal with punch
forceps or dissect with curved scissors.
In every case all adhesions should be first
carefully removed, as cutting the anterior

DONOVAN

693

pillar is very painful and liability to hem-
orrhage much increased.
By the local application of lo per cent, co-
cain combined with injection of Schleich's
solution, the operation is not painful. In
children, general anaesthesia, ether being
preferable, wil permit of cleaning the
naso-pharynx at the same time. Of late,
under general anaesthesia, using a mouth
gag, apply the tonsillotome by a sense of
touch only, combined with external pres-
sure ; thus am able to operate with much
greater rapidity, requiring the minimum
time and amount of the anaesthetic,. The
special plan to be adopted, must be de-
cided after a careful study of history,
physical conditions and general consid-
erations in each case. All things being
equal, immediate removal of the greater
portion if not the entire gland is prefer-
able. In adults, I favor complete removal
in most cases.

Butte, Montana.

The Main Traveled Route.— To the

Northwest it is the Chicago, Milwaukee
& St. Paul Railway. It is the best road,
has best train equipment, and best sleep-
ing car and dining car service. It is the
route of the United States Government
Fast Mail trains and of the famous Pi-
oneer Limited trains. If you go to the
Twin Cities of Minnesota or beyond go
via "The St. Paul Road" and ride on the
best train in the world.

All ticket agents sell tickets via Chi-
cago, Milwaukee & St. Paul Ry, For
descriptive literature address F. A. Mil-
ler, 'General Passenger Agent, Chicago.

Per Cent, of Heredity In Oxaluria.

— At the Congress of Hydrology, Clima-
tology, and Geology, Dr. Dedet reported
that out of 500 patients he had found 112
who, on admittance, during or at the end
of their illness, exhibited oxaluria. In
40 per cent, of these cases there was
heredity. — ( Medical Bulletin. )

MEDICAL CONSIDERATIONS.

1. Art is long, time fleeting; there-
fore, brevity is the cry of our confreres,
for "the bird of time hath but a little way
to fly, and lo! The bird is on the wing".

2. Success does not always imply
wealth, nor does it even imply a lucra-
tive and influential practice.

3. The oath of Hippocrates, so ex-
pressive of high medical morality or eth-
ics, is said to be "The most memorable
of human documents".

4. Never before in the world's his-
tory since Plato gave us his Dialogues of
Eryximachus, the son of Acumenus, has
medicine occupied such an exalted stand-
ing.

5. Are not the daughters of Eve, in
some respects, to be likened unto verbs — as
regular, irregular and defective? And as
for that one of those who are crying for
reforms and assuming to be the "new wo-
man", should that one be designated "it"
and "its" followers as "it's"? For there is
evidence of "neuter gender".

6. Co-education is losing the support
of those who have encouraged it and
watched its progress. The masculine
woman is not marketable nor attractive.

7. The sight of five or six young wo-
men, attenuated in form, writing on their
"finals" in medicine, is a sad reminder to
me of their misguided ambition and of
the fact that fools and their friends still
flourish.

8. Are not the gifts of the gods^
Asepsis, Sanitation and Anesthesia, equaled
only by that of fire, which the Titan stole
from the heavens?

9. When one possessed of such re-
markable gifts as was Virchow can fully
realize his strength and adaptability for
another duty in life's work, then, and
only then, is he a safe guide in medicine.
It is better, since Medicine is a jealous
mistress, to fully relinquish it if other in-
terests are more inviting.

10. Nationalism and Sectarianism in

694

MEDICAL CONSIDERATIONS

medicine are growing to be less counte-
nanced by our best thinkers. The sol-
idarity of our profession is becoming a
recognized condition and is encouraged
by those who love their profession for
its own sake.

11. If we, as members of the honora-
ble profession of medicine, were as true
to each other in regard to our schedule
of fees as are those who are of the clergy
and of the profession of law, we would
certainly free ourselves from much self-
condemnation, and thereby avoid public
condemnation. Tradesmen, in regard to
schedules of fees, are furnishing us with
easily read instructions.

12. The bestowal of specialist cer-
tificates by some cheap universities,
whose craze for notoriety and shekels is
equaled only by their ignorance of the
wants of the profession and their disre-
gard for its responsibility, is the greatest
injury to which our profession is being
subjected. State legislation and state
medical boards should denounce this evil
with no uncertain words.

13. State, or old established and well
endowed universities, should control
medical studies and alone grant the de-
gree of Doctor of Medicine. And joint-
stock medical concerns, conducting other
studies, such as pharmacy, etc., granting
cheap doctorates in each, should be well
ventilated, in fact, denounced. The dear
people, the thinking people, are respecting
such schools equally with commercial
colleges, expecting something better for
medicine. And are they to blame?

14. The popular delusion which will-
o'-the-wisp hunters hold so closely to
their hearts — such delusions (the pro-
mulgations of crazed and scheming per-
sons) as are called Osteopathy, Spiritual-
ism, Christian Science, Vitapathy, etc., —
should be tolerated, since such things
keep from asylums and mad houses those
who would otherwise become burdens to
the state.

15. No one can be a specialist — that
is, a safe one — who has not had several
years of experience in active general
practice and has chosen his specialty not
for its special revenue, but for his thor-
ough love and his especial gifts and prep-
aration for it.

16. If the New York University ob-
tained no names of physicians for its
Temple of Fame, it is indeed a sad reflec-
tion on the estimation of the worth of
men — such as Ephriam McDowell, Mar-
ion Sims (whose statue is in Bryant
park), Mott, Morton, Rush, Walter Reed,
Carroll and Agramonte, and others equal-
ly memorable, not forgetful of Jenner,
Roentgen, Virchow and Pasteur,

17. That quackery flourishes and is
encouraged is due to cheap medical
journalism ^nd to those of the profession
whose interest in it is purely of a finan-
cial character ; and an ordinary review of
the work of two or three medical journals
— each claiming the largest circulation —
will prove these statements. It is evi-
dent to the ordinary reader that subscrib-
ers thereto are looking for "sure cures"
and the editors and a few well-paid con-
tributors are directing the "innocents" to
"original packages", which are being
dished up around the corner by a con-
cern in which their capital is to a great
extent invested. That the poor, mis-
guided M. D.'s are easy victims is in evi-
dence, for the drugs made use of for these
patients, although they have a place in
the works on medicine, have no especial
merits named for them. The "Pharmacal
I X L Co.," however, has found them
? ? ? t ! !

18. "I am a part of all that I have
met" is a wise saying, equivalent to "A
man is known by the company he keeps"
and "Evil communications," etc. This
being the case, will not a few medical
journals (I say a few, but I could name
three-fourths of those published as ob-
jectionable) which vie with Police Ga-

MEDICAL CONSIDERATIONS

695

zettes and Journals in unnecessary
"smut" have a tendency to lower one's
estimation of the profession, his useful-
ness and his moral character? Such jour-
nals, and those which advertise "sure cures"
and other non-ethical preparations, should
be ostracized by the American Medical As-
sociation, and by the state and the provin-
cial associations. For the readers of such
journals are really fakirs and the encourag-
ers of fakirs edit such journals.

19. If those who, as pork packers, brew-
ers, speculators, etc., have rolled up millions
of shekels, thereby causing broken hearts,
disgraced families and innumerable woes,
wish to make atonement and to honor ( ?)
the men who made the wealth, would en-
dow a chair in the State University or en-
dow a college in affiliation with the State
University after the manner of those con-
nected with Oxford and with Cambridge
Universities, would not the state be better
benefitted than if a "John Humphrey Smith,
Sr." University were to be established ? Or
would it not be as well to endow a chair for
Medical Legislation and Ethics, for which
the "father of the American Medical Asso-
ciation", N. S. Davis, M. D., LL. D., was
so many years champion and earnest work-
er? Considering that doctors are rapidly
becoming the peers of Kings and Emperors
and Presidents, and that more than twenty
are baronets, are not better legislation, high-
er matriculation requirements in medicine,
etc., and Ethics the demands of the hour,
to make this century more glorious than
the past?

Leprosy Not Always Hereditary In

Girls. — An exchange says: "Incidental-
ly to the discussion now in progress as
to the advisability of lepers marrying,
the very interesting fact is brought out
that, according to Dr. W. O. Smith, who
has for years been the president of the
board of health of Hawaii, during the last
thirty years less than one per cent, of
the girls born of leprous parents showed
any taint after birth."

Give Art Its Mystery.

Never let a layman Into the knack of It;
Mr. Lay already thinks he has abundant witj

If you give him quinine, call It by som« sound
That his vocal organs cannot twist around.

Or, If It Is Epsom you are giving to
A patient, look out that he has not got onto you.
Keep your business silent; If you cure him now,
Make it all a mystery, do not tell him how.)

We have seen good doctors keep no doors or bllnda
On the store of precious things In their wondroual
minds;
They would cast their jewels at the feet of swine,
And their high unselfishness seemed almost divine.
The layman gets a notion, and this is how he
blows:
"Doc Brown will give you quinine— I guess it's all
he knows —
"Doc Jones charged me a dollar for wrltln' Io-
dine;
"Next time I'll go and buy it. He must think I
am green.
"Old Doctor Smith will dope you with morphine
till you're numb,
"And Doctor Clark just gives you plain mercury,
by gumf
"I think that our law>makers should make these
doctors know
"There ain't no kind of reason in usln' plzens so.
"It almost makes me shiver. Doc West, so people
say,
"Gave nitroglycerine to Sam the night he passed
away.
"I was readin' in the paper one day, not long
ago,
"And I saw an advertisement of a certain Dr.
Blow.
"He never gives a mineral, and don't use m.er-
curee
"Or any kind o' pizen stuff; he is the man for me."

Oh! Yes! There are good doctors

With no doors or blinds
On the store of precious things

In their wondrous minds.
They are casting jewels

To the swine that rend;
They are all forgetful

Of a selfish end.
But If they would sometime

Make the swine more pure.
They should save their jewels

For their connoisseur.

C. E. BOYNTON, M. D.
Los Bancs, Cal.

Blindness In France. — In a report to
the Ophthalmological Society, Dr. Trous-
seau states that the number of blind in
France reaches 31,966; a proportion of
8 in 10,000, This proposition is consid-
erably in excess of that in Denmark,
Switzerland, Austria, and above all, Hol-
land ; where it is exactly 4.46 in 10,000. —
(Medical News.)

696

EDITORIAL

Detroit riEDicAL Journal

A MONTHLY EPITOME OF
PRACTICE AND THCRAPCUTICS

FRANK BURR TIBBALS, M. D., Editor

COLLABORATORS

A. W. IVES, M. D. H. J. HARTZ, M. D.

JOSEPH SILL, M. D.

WALTER C. BOYNTON, Business Manager.

Note. — We do not assume responsibility for the opinions of
contributors.

The management cannot undertake to return rejected manu-
script unless full postage for the purpose is submitted with the
contribution -

Address all communications to 270 Woodward Avenue,
Detroit. Michigan, U. S. A.

Vol. 2. DETROIT, MICHIGAN. JANUARY, 1903.

No. 10

A SUGARED PILL.

Ever since competition in the drug
business assumed its present keenness,
numerous methods have been devised by
dealers to secure the patronage of the
physician. Sometimes it is gained by a
special discount, sometimes by the gift
of instruments, sometimes in other ways
that vv^alk on the verge of non-ethics. The
co-operative plan has been tried w^ith
varying success, but now a new idea in
this line is offered to the profession. For
ingenuity it is commendable, but ethically
it falls short of strict requirements.

In brief, the plan is as follows: The
company sells to the physician one hun-
dred shares of ten dollars each of six per
cent, cumulative preferred capital stock.
It may be paid up at once in cash by the
purchaser, or at any subsequent time, at
his option. If the purchaser wishes to
have the company carry his stock for
him, he insures his life for $i,ooo, and
assigns the policy, to be written on the
endowment plan, to the company, which
pays the premium out of the dividend of
six per cent. Any balance of the dividend
is paid to the stockholder. When the in-
surance matures, the stockholder, or his
estate (in the event of his death) has the
option of accepting the entire proceeds of
thepolicy or to pay the proceeds as sub-

scription for the stock ; in the latter case
any amount of the policy, over and above
the amount of principal remaining unpaic
on the stock, shall go to the stockholdei
or his estate. Incidentally, the stock
holder gives to the managers his proxj
irrevocable until he has in some way paic
for his stock. The proxy is incorporatec
in the agreement.

Now for the physician's duty. H<
agrees that he will in his practice pre
scribe "as far as he can consistently, anc
to a reasonable extent, as provided by th(
by-laws, from the regular formulas" o
the company. (The by-laws fix th(
amount at $2.00 a day, four 50 cent pre
scriptions, and a verbal agreement ii
made that the physician shall be com
pensated pro rata for any increase ovei
this.)

Close track is kept of each physiciai
and each druggist. The original package:
of the company's preparations, which ar(
to be prescribed by the stockholders beai
only the trade-mark of the company 01
the outside. With each package then
is an unattached label, bearing the nam(
of the contents, with space for the namt
of the druggist, the physician and th<
date. When a druggist fills a physician';
prescription for an original package h<
fills in his own name, the name of th(
prescribing physician and the date, anc
forwards the slip to the company. Foi
this he receives four cents, and the com
pany is furnished with a check on itj
business.

The agreement which the prospectiv<
stockholder is asked to sign specifies thai
only pure drugs are to be used in th(
preparations of the company, and thai
they shall be accurately prepared in the
manner shown by the formulas furnishec
to physicians; also that every holder oi
preferred or common stock shall have the
right to verify the quality of the prescrip-
tions at any time. (No provision is made
for an unfavorable finding in this regard

EDITORIAL

697

forming a basis for withdrawal from the
contract. The agreement is loosely word-
ed and elastic.)

As a business prospect for the holders
of common stock, the plan presents al-
most unlimited possibilities. The com-
pany is to have an elastic charter, run-
ning to $5,000,000. At first, $400,000 in
preferred stock will be issued to physi-
cians, and if it is found necessary more
of the same kind of stock will be issued.
A million in common stock will form the
first issue in that class. It is well known
that proprietaries in large quantities can
be bought very cheaply and on favorable
terms, so practically all the company
would need in money would be the estab-
lishment of a line of credit. If enough
physicians are secured to make the plan
feasible, no traveling men will be needed,
nor will the company be at any expense
for advertising. The physicians will
create a demand for the company's goods,
and druggists must stock them. One of
the arguments used by the company's
representatives is along this very line,
these statements being made to show
how cheaply the company can operate.
An office force and one or two shipping
clerks would be about all the company
would need to carry on its business.

The doctor is the essential factor in the
business. Without his prescriptions, the
company would be on the same footing as
regards competition and expenses as any
other drug house. The doctor is the im-
mediate means of income, and he gets
next to nothing for his work. Suppose
the average physician to be forty-five
years of age; the premium on a twenty-
year endowment policy would take prac-
tically all his dividends, and he would
have to "die to win," so he really loses
the chief attractive feature of endowment
insurance. His entire income in any form
would be sixty dollars a year, as provided
in the basis of dividend for the preferred
stock. The plan is unethical in the ex-

treme; it makes the prescription of pro-
prietaries a sine qua non; it ties the
physician hand and foot to one company,
with which he has not an equitable bus-
iness agreement. And he works for the
benefit of the holders of the common
stock. Most physicians are used to work-
ing for the benefit of others, without
much material gain; but in this case it
appears that the physician is to take
medicine, thinly disguised with sugar, for
another. And medicine by proxy is al-
ways distasteful to the taker.

THE PERSISTENCE OF THE MIDWIFE.

In the matter of securing legislation
along medical lines, the ultimate object ot
which is the benefit of suffering humanity,
the profession might well turn its atten-
tion to securing the passage of laws which
should do away with the old-fashioned,
untrained, ignorant women who from
time out of mind have been assisting chil-
dren into the world, and out of it, some-
times with the mother into the bargain.
The horrors of child-bed without any
sort of pretense at cleanliness are not un-
familiar to any physician whose prac-
tice carries him among the families of the
poor — families who call him in to undo
or to repair the work of the midwife, and
then, because he is too late, return with
increased devotion to her at the next con-
finement, providing that she has lett a
mother capable of bearing children again.
How many cases of puerperal fever, how
many children blinded with gonorrhoea,
how many helpless mothers permitted to
bleed to death, have been the result of the
ministrations of ignorant women, will
probably never be known.

The profession owes it to its members,
and to humanity, to take some steps by
which the terribly high mortality which
results from the attendanceof the mid-
wife may be lessened. Dr. Thomas Scott
Hening, of Winterpock, Va., in a recent
number of the Virginia Medical Semi-

698

EDITORIAL

Monthly, reports a number of particularly-
sad cases which have come under his ob-
servation, in w^hich the life of the child,
or the mother, or both, have paid the pen-
alty of mid-wife attendance. The condi-
tion of things which he describes in the
south is no worse than it is further north,
for the mid-wife is like the poor — always
with us. Her chief requisites for practice
are that she shall be old, and that she
shall do her work cheap. Her trade must
be plied among the ignorant and the
lowly, for no other person will employ
her. She is unclean, unlettered, and with-
out shame. She bases her practice on tra-
dition, and her power among her clients
is almost unlimited. Every old woman
in the neighborhood feels it her duty to
assist her and the wonder is that children
are born to live at all, with all of them
in attendance.

Let this matter be agitated. Where
there are laws already, let them be en-
forced, so that they shall mean some-
thing. Make the penalty heavier, where
one already exists. Where there are no
laws, let the profession bend its energies
to securing the pasage of suitable legisla-
tion.

ANTI-CONSUMPTION WORK IN
PENNSYLVANIA.

Like many others of the states in the
Union, Pennsylvania is taking a lively in-
terest in the problem of how best to com-
bat the ravages of consumption. The es-
tablishment of the free hospital at White
Haven has thoroughly demonstrated the
need of further hospital facilities for the
care of needy consumptives, since the
waiting list at that institution has been
nearly double the capacity of the hos-
pital. The medical society of the state
reports that about 8,000 deaths from con-
sumption occur annually in Pennsylvania
and that there are at all times at least
10,000 people who are suffering from the
disease.

The Lackawanna County Medical So
ciety has recently started an agitation foi
equipment with which the county ma)
make a successful fight against the spreac
of tuberculosis and if the efforts of th(
physicians in that portion of the stat(
prove to be successful, the work will un^
doubtedly spread further. The Lacka
wanna plan includes the establishment o:
a municipal laboratory, the registratior
of tuberculosis by attending physicians, i
sanitorium for the treatment of cases, an('
especially the dissemination ot knowl-
edge by means of circulars and addresses
to the people. The success of this plar
has already been demonstrated in the na-
tional metropolis, where the death ratt
from consumption has fallen nearly 3 =
per cent, since the introduction of educa-
tional measures in the city.

There is little doubt that there is need
for instruction to the public in regard tc
the possibility of spreading the disease
through carelessness on the part of the
patient or his family. The establishment
of a municipal laboratory is to be com-
mended, and the sanitorium, in view oi
the statistics furnished, is a necessity
With these things, and the co-operatior
of the medical profession, which appears
to be already assured, owing to the inter-
est which Pennsylvania physicians as a
body are taking in the matter, the re-
sults should be certain.

H;DIToH£^L

An interesting explanation for the
large number of crimes against women
which are annually committed by
negroes, particularly in the south, is furn-
ished in a editorial in a recent number of
the Charlotte Medical Journal. The key-
note of the comment is this: "The cause
that keeps the white man ever on the

EDITORIAL NOTES

699

alert, that frightens and terrorizes the
white women and little girls, that has
made farms vacant and sent the owners
to cities, is the periodical uncontrollable
sexual madness of individuals born of a
race whose biologic animal potentialities
can no more be changed by education and
environment than can their woolly hair
be made straight by careful and constant
combing."

The writer then goes on: "These
physiologic laws are immutable; they
cannot be governed by moralists nor sup-
pressed by ethical culture. The want ot
training along the lines of anthropology
and physiology that exists among the
class which believes that social recogni-
tion and ethical culture will change cer-
tain centers in the brain of the African as
well as reduce his physiologic activity, is
an humiliating evidence of their ignorance
of anthropologic facts." It is pointed out
that there is always an increase in crime
against property among the negroes in
the winter, and the statement is made
that crimes against women are most fre-
quent in May and June, and least so in
November and December. It is at least
an interesting theory, and, from the stand-
point of a very large number of southern-
ers, an absolutely tenable one.

Physicians who do even a cursory
reading of medical periodicals must have
seen an article on "Septicemia and the
Curette", which has enjoyed an un-
precedented publication in the medical
journals of the country for several
months past. A recent issue of the St.
Louis Clinique, which contains the article
in question, has a somewhat naive com-
ment to make in its columns. It says :

"A paper in this issue of the Clinique on
'Septicemia and the Curette' contains
some valuable suggestions, but fails to
accurately state what alkaline solution is
intended for use in this way. The editor
would suggest the employment of a wash

made by dissolving eight of Seiler's al-
kaline and antiseptic tablets in a pint of
warm water as a proper "alkaline" solu-
tion for the purpose. The author of the
paper would probably refer inquirers to
some proprietary preparation, the paper
probably being designed as a means ot
advertising something of that character."
Immediately upon reading the forego-
ing, one asks the question, "What on
earth did you want to publish it for? If
you knew or suspected that it was writ-
ten largely for the purpose of advertising
some proprietary preparation, why did
you give it space?" The editor has evi-
dently been caught napping, as all of us
are likely to be sometimes. If he didn't
think the article in question was really
calculated to interest and instruct his
readers, he ought not to have used it at
all.

A new departure has been undertaken
by the publishers of The Chicago Clinic
and Pure Water Journal, published in Chi-
cago by Dr. George Thomas Palmer. It
consists of a free bureau of information
as to the value of American sanitaria
and health resorts, with descriptions of
mineral springs, if any, climatic advant-
ages and disadvantages, hotel rates and
so forth. The journal undertakes to for-
ward to any inquiring physician such
data as its management has at hand in
regard to the numerous health resorts of
the country without charge. The paucity
of good and reliable information on these
matters, and the large number of resorts
which claim special advantages for pa-
tients furnish a large field for the workr
of the bureau, and we trust that it may
be successful.

Oxford recently conferred the hon-
orary degree of Doctor of Science on Dr.
Charles S. Minot, professor of histology
and embryology in the Harvard Medical
School.

700

NEW INSTRUMENTS AND DEVICES

AI^STB^MENT/

Mention of new instruments and devices in
this department is entirely complimentary and
articles Illustrated are judged on their merits.

We Invite manufacturers and physicians to
send us matter suitable for publication under
this head. A description of the device and an
electrotype or half-tone with a base not greater
than two and five-eighths Inches should be sent.

Always mention the price of the article In
question.

The management cannot undertake to return
cuts unless postage for same accompanies the
letter with which they are sent.

PARAFFIN INJECTION SYRINGE.

The value of paraffin injections in plastic
operations for restoring and benefitting
facial deformities has been recognized by
the profession almost ever since Gersuny,
of Vienna, first introduced his method of
injection. Recent literature is full of com-
ment on the operation and the necessary
paraphernalia, and among the late contribu-
tions on the subject may be mentioned the
following: Wiener Klinische IVochen-
schrift, June 20, 1901 ; American Medicine,
December 7, 1901 ; Journal of the American
Medical Association, April 19, 1902;
Deutsche Mcdisin. Wochenschrift, Dr. Eck-
stein, August 7, 1902; St. Paul Medical
Journal, September, 1902; Medical Review
of Rcviezvs, September 25, 1902; Medical
News, November 29, 1902. The necessity
for absolute aseptic conditions in cosmetic
operations is not to be doubted, and the
need of keeping the paraffin from solidify-
ing tod rapidly must be obvious. Two
syringes which have recently been put out
meet both these conditions, being carefully
constructed with these ends in view. Both
are easily rendered aseptic, and with ordi-
nary care the paraffin used in them will
not cool so quickly as to render its manipu-
lation by the surgeon difficult of accomplish-
ment.

With the syringes comes a device for
holding the bottle full of paraffin, so that
the latter may be placed in hot water to

H

admit of its being softened. The paraffin
used is specially prepared for the use to
which it is intended to be put. The
syringes retail for $5.00 apiece, the bottle-
holder for $2.00, and the bottle of paraffin
for 50 cents.

ELECTRICAL MEDICAL COIL.

In these days of the increased attention
which is being given to massage of all kinds,
this is a convenient device for the physician
to keep in his office. It is very compact
and very handy. A small battery is in-
serted in one end of the stock, and the pres-
sing down of a small button completes a
circuit which generates a mild current of
electricity. Pulling out the free end of the
stQck increases the strength of the current,
which may thus be controlled by the opera-
tor. A scale on the side of the coil indi-
cates the strength of the current which is
being administered. Self-massage is a

NEW INSTRUMENTS AND DEVICES

701

simple matter with this device. A sponge
roller is provided which can be placed in
one end of the coil, and the operator holds
the stock in his hand, rolling the sponge
over the part which it is desired to
massage. The compact design of the de-
vice permits it to be carried in a small

easily through a valve opening outward.
The front of the device is perforated and
the incoming air is filtered through a com-
bination of silk and sponge which effectual-
ly removes from it dust, smoke, fumes and

space, and it is not heavy. Extra bat-
teries are supplied by the manufacturer
at the price of ten cents each, and it is es-
timated that in ordinary use the coil will
last several months without renewing. The
price of the coil outfit, complete with bat-
tery, sponge and so forth, is $3.00.

COMBINATION RESPIRATOR.

This device consists of a mouth-piece
somewhat similar to those in use with nebu-
lizers, made of soft white rubber and de-
signed to fit closely over the nose and
mouth. It is secured by means of a rubber
band passing over the ears and around the
back of the head, and the wearer breathes

odors. The worker in a chemical labora-
tory might find it helpful, and the surgeon
who is performing a disagreeable operation
may readily see a means for making it use-
ful. The material of which it is made ad-

mits of its being rolled up and slipped into
the pocket or a corner of the instrument-
bag. The manufacturers have had a large
experience in manufacturing respirators,
and they ask $2.00 for this particular one.

The Ingham County Medical Society
held its annual meeting on the 8th inst.,
at the home of the Vice-President, Dr. H.
A. Haze, Lansing. Dr. Reuben Peterson,
of the University of Michigan, read a
paper on "The Surgical Treatment of
Procidentia."

702

BOOK REVIEWS

A Pocket Text-Book of Dermatology.
By Joseph Grindon, M. D., Professor of
Clinical Dermatology and Syphilis in
the Medical Department of Washing-
ton University, St. Louis. In one i2mo
volume of 367 pages, with 39 illustra-
tions in black and colors. Lea's Series
of Pocket Text-Books. Edited by
Bern B. Gallaudet, M. D. Cloth, $2.00,
net; Limp Leather, $2.50, net. Lea
Bros. & Co., Publishers^ Philadelphia
and New York.

Dr. Grindon's thorough familiarity
with the subject of which he writes, not
only in view of modern practice but also
in the light of experience from previous
teachings , makes him an interesting
author. The book is concise, closely and
carefully written. Here the student may
find definite information on a subject that
should be of great interest to him; here
also the advanced practitioner and even
the specialist may find something of
value. The text is carefully classified
and arranged with a view to providing
much authorative information in as small
a space as possible. The division into
sections, each disease being treated as a
unit, and the fulness with which the im-
portant subjects of pathology and treat-
ment are treated strongly recommend the
book to the consideration of the profes-
sion.

Numerous illustrations, chiefly those of
Dr. John F. Keber's cases, illumine the
text and afford valuable diagnostic mater-
ial for the reader.

western University Medical School,
Chicago. New (3d) Edition, Enlarged
and Thoroughly Revised. In one very
handsome Octavo Volume of 756 Pages,
with 474 Engravings, of which 60 are
in Colors, and 22 Colored Plates. Cloth,
$5.00 Net. Leather, $6.00 Net. Half
Morocco, $6.50 Net. Lea Bros. & Co.,
Philadelphia and New York.
Dudley's book needs no introduction to
the profession, among the members of
which it already numbers many friends.
The book in its third edition bids fair to
add a large number to those who already
look upon this book as an almost indis-
pensable aid to a knowledge of gynecolo-
gy. Nearly one hundred pages of text
have been added to the second edition,
but the rewriting and condensation that
has been done by the author admits of the
additional text being incorporated in this
present addition without adding much to
the bulk of the book. The process of
revision has brought the book thoroughly
into accord with the best and latest mod-
ern practice, and a number of new
illustrations, showing a number of the
minor operative manipulations have been
introduced. Tables used in presenting
etiology, pathology, physical signs, dif-
ferential diagnosis, and so on, have been
utilized to save space, while they afford
an excellent ready reference for the read-
er. The illustrations are almost uniform-
ly of a high order and the publishers have
evidently devoted no little care to this
edition of Dudley's Gynecology.

Dudley's Gynecology. A Treatise on the
Principles and Practice of Gynecology,
By E. C. Dudley, A. M., M. D., pro-
fessor of Gynecology in the North-

Practical Gynecology, Obstetrics and the
Menopause. By A. H. P. Leuf, M. D.,
Philadelphia. Three Parts, complete
in one Volume of 326 pages. Price,
Cloth, $2.50. Published by the Medical
Council, 4105 Walnut St., Philadelphia,
Pa.

Non-essentials do not appear in this
book by Leuf. His language is simple,
forceful and convincing, and his style

BOOK REVIEWS

703

is that of a man accustomed to push
truths home to students. He is a very-
positive writer and he gives the benefit of
his own experience to his readers in a
manner that can scarcely help being of
use to them. Dr. Leup believes that too
much is made of the necessity for an ex-
pensive instrumental equipment for do-
ing gynecological work, and he sets down
the names of the indispensable instru-
ments and their prices in a most encour-
aging way.

The book as a whole consists of re-
issues of some series of papers, some
editorials and some scattered paragraphs,
published from time to time in the pages
^f the Medical Council and now gathered
into convenient form for reference and
information. The author believes that
the average general practitioner is too
easily overawed by the claims of the gyn-
ecologic specialist, who does so much
work in the present day, and one of the
Dbjects of the original issue of his writ-
ings was to do away with this condition
3f affairs. Leuf believes that greater
Familiarity with the conditions leading to
md present in diseases of women will
iiave the effect of giving the general prac-
titioner more confidence in himself and
iiis ability to do successfully much of the
work now being done by specialists. The
30ok has been strongly endorsed by the
nembers of the profession who have al-
ready read it. It is not too expensive